Provider Demographics
NPI:1700931037
Name:ASSOCIATES OF FAMILY DENTISTRY
Entity type:Organization
Organization Name:ASSOCIATES OF FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-865-2248
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-0016
Mailing Address - Country:US
Mailing Address - Phone:706-865-2248
Mailing Address - Fax:706-219-2051
Practice Address - Street 1:549 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528
Practice Address - Country:US
Practice Address - Phone:706-865-2248
Practice Address - Fax:706-219-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty