Provider Demographics
NPI:1679969380
Name:ADVANCED DENTAL ARTS, LLC
Entity type:Organization
Organization Name:ADVANCED DENTAL ARTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:MUFID
Authorized Official - Last Name:OTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:478-207-6939
Mailing Address - Street 1:4705 NORTHSIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1698
Mailing Address - Country:US
Mailing Address - Phone:478-207-6939
Mailing Address - Fax:478-254-9638
Practice Address - Street 1:4705 NORTHSIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1698
Practice Address - Country:US
Practice Address - Phone:478-207-6939
Practice Address - Fax:478-254-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014686261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental