Basic Information
| Provider Information | |||||||||
| NPI: | 1285745505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | DAVIS | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 BOAT ROCK RD SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303317316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043106548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1536 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787814333 | ||||||||
| FaxNumber: | 4787814331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN011029 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000471875 | 05 | GA | MEDICAID | 1429244 | 01 | GA | UNITED CONCORDIA | OTHER | 100759 | 01 | GA | AVESIS | OTHER | 9180606 | 01 | GA | DENTAQUEST | OTHER |