MEDICARE: GWINNETT GENERAL DENTISTRY

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	011818	GA

General Provider Information

NPI Number	:	1821259854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT GENERAL DENTISTRY

Provider Business Mailing Address
First Line	:	3100 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE 201
City	:	LILBURN
State	:	GA
Zip	:	30047-1890
Country	:	US
Telephone Number	:	770-978-3292
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE 201
City	:	LILBURN
State	:	GA
Zip	:	30047-1890
Country	:	US
Telephone Number	:	770-978-3292
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DONNA LONG
Credential	:
Telephone Number	:	770-978-3292

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	06/23/2008

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