Provider Demographics
NPI:1871943662
Name:MALL OF GEORGIA DENTISTRY
Entity type:Organization
Organization Name:MALL OF GEORGIA DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-714-6343
Mailing Address - Street 1:1905 MALL OF GEORGIA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519
Mailing Address - Country:US
Mailing Address - Phone:678-714-6343
Mailing Address - Fax:678-714-6345
Practice Address - Street 1:1905 MALL OF GEORGIA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519
Practice Address - Country:US
Practice Address - Phone:678-714-6343
Practice Address - Fax:678-714-6345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0124411223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty