Organization
GA SOUTHERN DENTAL LLC
Active
Parent organization
GA SOUTHERN DENTAL LLC
Other names
Northside Dentistry
Organization subpart
Yes
Provider details
NPI number
Legal business name
GA SOUTHERN DENTAL LLC
Authorized official
ERIKA MELISSA MENJIVAR (SR. CREDENTIALING SPECIALIST)
(469) 596-6137
Entity
Organization
Contact information
Practice address
3298 NORTHSIDE DR, MACON, GA 31210-2553
(478) 475-1976
Mailing address
5830 GRANITE PKWY STE 780, PLANO, TX 75024-6775
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Enumeration date
10/02/2024
Last updated
10/02/2024
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