Provider Demographics
NPI:1447475959
Name:GRIFFIN DENTAL SPECIALTIES
Entity type:Organization
Organization Name:GRIFFIN DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CLELAND
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-412-6575
Mailing Address - Street 1:218 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-2810
Mailing Address - Country:US
Mailing Address - Phone:770-412-6575
Mailing Address - Fax:770-412-9089
Practice Address - Street 1:218 S 11TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-2810
Practice Address - Country:US
Practice Address - Phone:770-412-6575
Practice Address - Fax:770-412-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty