Healthcare Provider Details

I. General information

NPI: 1922553676
Provider Name (Legal Business Name): CRABAPPLE ORTHO AND PEDO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12385 CRABAPPLE RD STE 100
ALPHARETTA GA
30004-6357
US

IV. Provider business mailing address

12385 CRABAPPLE RD STE 100
ALPHARETTA GA
30004-6357
US

V. Phone/Fax

Practice location:
  • Phone: 770-901-2369
  • Fax:
Mailing address:
  • Phone: 770-901-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER SNOW
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 404-410-1340