Basic Information
| Provider Information | |||||||||
| NPI: | 1851366462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YOUTH DENTISTRY OF MACON, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1536 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787814333 | ||||||||
| FaxNumber: | 4787814331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1536 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787814333 | ||||||||
| FaxNumber: | 4787814331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2006 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZOELLER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, LEGAL LICENSING & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4787814333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1905601 | 01 | GA | UNITED CONCORDIA | OTHER | 478300670A | 05 | GA | MEDICAID | 539109 | 01 | GA | AVESIS | OTHER |