Healthcare Provider Details

I. General information

NPI: 1699380840
Provider Name (Legal Business Name): POLISH DENTAL CENTER ALPHARETTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 VALAIS CT STE 102
ALPHARETTA GA
30022-2606
US

IV. Provider business mailing address

692 LONDONBERRY RD
ATLANTA GA
30327-4956
US

V. Phone/Fax

Practice location:
  • Phone: 770-642-4711
  • Fax:
Mailing address:
  • Phone: 202-714-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY JAMISON
Title or Position: OWNWER
Credential: DDS
Phone: 202-714-8433