MEDICARE: TREMONT ROAD DENTAL, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	1223E0200X	Endodontics
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619262391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREMONT ROAD DENTAL, PC

Provider Business Mailing Address
First Line	:	210 INTERSTATE NORTH PKWY SE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2233
Country	:	US
Telephone Number	:	770-916-9000
Fax Number	:	678-247-7858

Provider Business Practice Location Address
First Line	:	365 LOWES DR
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-5900
Country	:	US
Telephone Number	:	770-916-9000
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PAYOR RELATIONS
Name	:	MICHELLE JACOMINO
Credential	:
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	05/27/2022

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