MEDICARE: DDD FOUNDATION, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1265642094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DDD FOUNDATION, INC

Provider Business Mailing Address
First Line	:	52 EXECUTIVE PARK SOUTH NE
Second Line	:	SUITE 5203
City	:	ATLANTA
State	:	GA
Zip	:	30329-2217
Country	:	US
Telephone Number	:	404-942-0086
Fax Number	:	208-955-2434

Provider Business Practice Location Address
First Line	:	52 EXECUTIVE PARK SOUTH NE
Second Line	:	SUITE 5203
City	:	ATLANTA
State	:	GA
Zip	:	30329-2217
Country	:	US
Telephone Number	:	404-942-0086
Fax Number	:	208-955-2434

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEIDRA RONDENO
Credential	:	DDS
Telephone Number	:	404-942-0086

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	03/26/2013

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