Organization
EAGLIN DENTAL GROUP, FAYETTEVILLE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TRACIE DENNEY (OWNER)
(770) 716-2701
Entity
Organization
Contact information
Practice address
692 GLYNN ST N STE S, FAYETTEVILLE, GA 30214-6705
(770) 716-2701
(770) 716-2718
Mailing address
692 GLYNN ST N STE S, FAYETTEVILLE, GA 30214-6705
(770) 716-2701
(770) 716-2718
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DN013169
GA
1223P0221X
Pediatric Dentistry
DN013169
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
777472578D
—
GA
Enumeration date
10/26/2011
Last updated
05/10/2012
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