Healthcare Provider Details

I. General information

NPI: 1487061214
Provider Name (Legal Business Name): BRACES BRACES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 COBB PKWY NW STE 160
ACWORTH GA
30101-8379
US

IV. Provider business mailing address

150 PROMINENCE POINT PKWY SUITE 500
CANTON GA
30114-9108
US

V. Phone/Fax

Practice location:
  • Phone: 770-222-2322
  • Fax:
Mailing address:
  • Phone: 770-479-9999
  • Fax: 770-479-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013593
License Number StateGA

VIII. Authorized Official

Name: MR. FARSHID HAMIDI NIA
Title or Position: ORTHODONTIST
Credential: DMD, MSD
Phone: 770-222-2322