Healthcare Provider Details

I. General information

NPI: 1174491187
Provider Name (Legal Business Name): DENTAL TOWN EMERGENCY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CUMMING HWY STE 100
CANTON GA
30115-8071
US

IV. Provider business mailing address

2970 BRANDYWINE RD STE 200
ATLANTA GA
30341-5549
US

V. Phone/Fax

Practice location:
  • Phone: 770-741-0439
  • Fax:
Mailing address:
  • Phone: 770-692-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JO ANN RICE
Title or Position: CREDENTIALING & ENROLLMENT DIRECTOR
Credential:
Phone: 470-881-8679