Provider Demographics
NPI:1609998483
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:615 GREEN ST NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3378
Mailing Address - Country:US
Mailing Address - Phone:770-532-2336
Mailing Address - Fax:770-536-3905
Practice Address - Street 1:615 GREEN ST NW
Practice Address - Street 2:SUITE 101
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3378
Practice Address - Country:US
Practice Address - Phone:770-532-2336
Practice Address - Fax:770-536-3905
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0111071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty