Provider Demographics
NPI:1902679913
Name:GA SDS, PC
Entity Type:Organization
Organization Name:GA SDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING AND PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:1610 54TH AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1442
Mailing Address - Country:US
Mailing Address - Phone:615-678-0759
Mailing Address - Fax:
Practice Address - Street 1:1380 PEACHTREE INDUSTRIAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3793
Practice Address - Country:US
Practice Address - Phone:770-232-1191
Practice Address - Fax:770-232-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery