Healthcare Provider Details

I. General information

NPI: 1649080037
Provider Name (Legal Business Name): DEPEW AND YOUNG ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 CEDARCREST RD
ACWORTH GA
30101-6404
US

IV. Provider business mailing address

2161 CEDARCREST RD
ACWORTH GA
30101-6404
US

V. Phone/Fax

Practice location:
  • Phone: 770-974-8255
  • Fax:
Mailing address:
  • Phone: 770-974-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DONALD DOUGLAS DEPEW
Title or Position: ORGANIZER
Credential: DMD, MS
Phone: 770-422-3939