Healthcare Provider Details

I. General information

NPI: 1780456301
Provider Name (Legal Business Name): TOWN DENTISTRY BROOKHAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 TOWN BLVD NE STE 2010
BROOKHAVEN GA
30319-3147
US

IV. Provider business mailing address

804 TOWN BLVD NE STE 2010
BROOKHAVEN GA
30319-3147
US

V. Phone/Fax

Practice location:
  • Phone: 404-631-6277
  • Fax:
Mailing address:
  • Phone: 404-631-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: HEATHER RAE FRODGE
Title or Position: OWNER
Credential: DMD
Phone: 404-476-0814