Healthcare Provider Details

I. General information

NPI: 1073408340
Provider Name (Legal Business Name): DENTISTRY OF BROOKHAVEN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 JOHNSON FERRY RD NE STE 2A
BROOKHAVEN GA
30319-2203
US

IV. Provider business mailing address

10930 CRABAPPLE RD STE 106
ROSWELL GA
30075-5825
US

V. Phone/Fax

Practice location:
  • Phone: 770-651-1000
  • Fax: 678-212-1973
Mailing address:
  • Phone: 770-651-1000
  • Fax: 678-212-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LEE CASEMENT
Title or Position: BILLING COLLECTIONS
Credential:
Phone: 770-651-1000