Healthcare Provider Details

I. General information

NPI: 1952792053
Provider Name (Legal Business Name): MOBILE DENTAL OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 PEACHTREE DUNWOODY RD BLDG E STE 101
ATLANTA GA
30328-6049
US

IV. Provider business mailing address

6111 PEACHTREE DUNWOODY RD BLDG E STE 101
ATLANTA GA
30328-6049
US

V. Phone/Fax

Practice location:
  • Phone: 773-756-5760
  • Fax: 773-714-1229
Mailing address:
  • Phone: 773-756-5760
  • Fax: 773-714-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STANFORD PLAVIN
Title or Position: PRESIDENT
Credential: MD
Phone: 773-756-5760