MEDICARE: CCSD-HAMILTON MILL,LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1790256758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCSD-HAMILTON MILL,LLC

Provider Business Mailing Address
First Line	:	2725 HAMILTON MILL RD STE 700
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-6010
Country	:	US
Telephone Number	:	770-932-8577
Fax Number	:	770-932-3277

Provider Business Practice Location Address
First Line	:	2725 HAMILTON MILL RD STE 700
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-6010
Country	:	US
Telephone Number	:	770-932-8577
Fax Number	:	770-932-3277

Authorized Official
Title or Position	:	OWNER
Name	:	NOORDIN K NURANI
Credential	:	DMD
Telephone Number	:	770-932-8577

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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