Healthcare Provider Details

I. General information

NPI: 1578003349
Provider Name (Legal Business Name): LRDJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 HUFF RD NW APT 4055
ATLANTA GA
30318-4373
US

IV. Provider business mailing address

60 CARRIAGE OAKS DR
TYRONE GA
30290-1684
US

V. Phone/Fax

Practice location:
  • Phone: 301-674-8761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberDN014757
License Number StateGA

VIII. Authorized Official

Name: DR. JULIAN STEWART
Title or Position: ORTHODONTIST/CEO
Credential: D.D.S
Phone: 301-674-8761