Provider Demographics
NPI:1861767253
Name:WEST GEORGIA DENTISTRY FOR CHILDREN
Entity type:Organization
Organization Name:WEST GEORGIA DENTISTRY FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BINGHAM-SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-384-1787
Mailing Address - Street 1:3827 JIMMY LEE SMITH PKWY
Mailing Address - Street 2:SUITE 121
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2804
Mailing Address - Country:US
Mailing Address - Phone:678-384-1787
Mailing Address - Fax:678-384-1459
Practice Address - Street 1:3827 JIMMY LEE SMITH PKWY
Practice Address - Street 2:SUITE 121
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2804
Practice Address - Country:US
Practice Address - Phone:678-384-1787
Practice Address - Fax:678-384-1459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061104501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156788755Medicaid