Provider Demographics
NPI:1053139519
Name:GA SOUTHERN DENTAL LLC
Entity type:Organization
Organization Name:GA SOUTHERN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:MENJIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-596-6137
Mailing Address - Street 1:5830 GRANITE PKWY STE 780
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3298 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2553
Practice Address - Country:US
Practice Address - Phone:478-475-1976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GA SOUTHERN DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty