Healthcare Provider Details

I. General information

NPI: 1093990327
Provider Name (Legal Business Name): BUCKHEAD PERIODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2008
Last Update Date: 01/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 PEACHTREE RD NW SUITE #622
ATLANTA GA
30305-2192
US

IV. Provider business mailing address

2970 PEACHTREE RD NW SUITE #622
ATLANTA GA
30305-2192
US

V. Phone/Fax

Practice location:
  • Phone: 404-261-9593
  • Fax: 404-261-9409
Mailing address:
  • Phone: 404-261-9593
  • Fax: 404-261-9409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN009901
License Number StateGA

VIII. Authorized Official

Name: DR. LAURA DAY BRASWELL
Title or Position: OWNER
Credential: D.D.S.
Phone: 404-261-9593