Healthcare Provider Details

I. General information

NPI: 1487145272
Provider Name (Legal Business Name): PEYTON HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
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

11 S MILL ST STE 200
NEW CASTLE PA
16101-3680
US

V. Phone/Fax

Practice location:
  • Phone: 770-203-1711
  • Fax:
Mailing address:
  • Phone: 724-698-2132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN015629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: