Provider Demographics
NPI:1144659996
Name:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Entity type:Organization
Organization Name:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRED. SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:2625 OLD WINDER HWY STE G
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-7021
Mailing Address - Country:US
Mailing Address - Phone:855-343-4056
Mailing Address - Fax:
Practice Address - Street 1:2625 OLD WINDER HWY STE G
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-7021
Practice Address - Country:US
Practice Address - Phone:855-343-4056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty