Healthcare Provider Details

I. General information

NPI: 1841638152
Provider Name (Legal Business Name): MICHAEL MINA GUIRGUIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2013
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30311-1636
US

IV. Provider business mailing address

2600 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30311-1636
US

V. Phone/Fax

Practice location:
  • Phone: 404-564-7749
  • Fax:
Mailing address:
  • Phone: 404-564-7749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN015285
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: