Basic Information
| Provider Information | |||||||||
| NPI: | 1528107943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STOCKBRIDGE DENTAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 CORPORATE CENTER CT | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782896707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 CORPORATE CENTER CT | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782896707 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLANAGAN | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DISTRICT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6782896707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.