Healthcare Provider Details

I. General information

NPI: 1043571672
Provider Name (Legal Business Name): PHDENTALPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2859 PACES FERRY RD SE SUITE 530
ATLANTA GA
30339-5701
US

IV. Provider business mailing address

2859 PACES FERRY RD SE SUITE 530
ATLANTA GA
30339-5701
US

V. Phone/Fax

Practice location:
  • Phone: 678-355-8980
  • Fax: 770-405-8855
Mailing address:
  • Phone: 678-355-8980
  • Fax: 770-405-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN12114
License Number StateGA

VIII. Authorized Official

Name: DR. HAROLD PEREZ
Title or Position: OWNER
Credential:
Phone: 678-355-8980