Organization
QUITMAN FAMILY DENTISTRY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LARRY M BLACK JR. DMD (OWNER)
(229) 263-8700
Entity
Organization
Contact information
Practice address
1306 E. SCREVEN STREET, QUITMAN, GA 31634
(229) 263-8700
Mailing address
1306 E. SCREVEN STREET, QUITMAN, GA 31634
(229) 263-8700
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
DN012932
GA
261QD0000X
Dental Clinic/Center
DNSC000233
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003124373A
—
GA
Enumeration date
08/07/2012
Last updated
08/07/2012
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