MEDICARE: EAST 53RD STREET DENTAL-2, P.C.

Medicare Provider Information

Scope of Practice

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

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

General Provider Information

NPI Number	:	1881778801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST 53RD STREET DENTAL-2, P.C.

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE STE 150
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6407
Country	:	US
Telephone Number	:	770-916-5036
Fax Number	:	678-285-4760

Provider Business Practice Location Address
First Line	:	2248 E 53RD ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-3479
Country	:	US
Telephone Number	:	317-472-9888
Fax Number	:	317-257-7028

Authorized Official
Title or Position	:	CHIEF DENTAL OFFICER
Name	:	DR. DAVID VIETH
Credential	:
Telephone Number	:	770-916-9000

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	05/13/2019

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