Organization
AVALA DENTAL PROVIDERS,LLC
Active
Other names
Polish Dental Center,LLC
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TIFFANY N JAMISON DMD (OWNER)
(770) 696-4144
Entity
Organization
Contact information
Practice address
629 A BEAVER RUIN RD, LILBURN, GA 30047
(770) 696-4144
(470) 545-2859
Mailing address
629 A BEAVER RUIN RD, LILBURN, GA 30047
(770) 696-4144
(470) 545-2859
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
DN014034
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1487953741
—
GA
Enumeration date
10/30/2013
Last updated
10/30/2013
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