Provider Demographics
NPI:1780017822
Name:PALMETTO FAMILY DENTAL OF PIKE COUNTY
Entity type:Organization
Organization Name:PALMETTO FAMILY DENTAL OF PIKE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-567-8000
Mailing Address - Street 1:15988 BARNESVILLE ST.
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295
Mailing Address - Country:US
Mailing Address - Phone:770-567-8000
Mailing Address - Fax:770-567-8600
Practice Address - Street 1:15988 BARNESVILLE ST.
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295
Practice Address - Country:US
Practice Address - Phone:770-567-8000
Practice Address - Fax:770-567-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013693261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA685019718CMedicaid