Healthcare Provider Details

I. General information

NPI: 1043766322
Provider Name (Legal Business Name): MOUNTAIN VIEW DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 BAKER RD NW SUITE B
ACWORTH GA
30101-6842
US

IV. Provider business mailing address

2320 BAKER ROAD SUITE B
ACWORTH GA
30101
US

V. Phone/Fax

Practice location:
  • Phone: 770-429-8989
  • Fax: 770-429-1997
Mailing address:
  • Phone: 770-429-8989
  • Fax: 770-429-1997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9192
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. HELEN DEANNE RHINESMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-429-8989