Healthcare Provider Details

I. General information

NPI: 1821316092
Provider Name (Legal Business Name): BRIAN A BAIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 DIXIE ST
CARROLLTON GA
30117-4415
US

IV. Provider business mailing address

429 MITCHELL AVE
BOWDON GA
30108-1405
US

V. Phone/Fax

Practice location:
  • Phone: 770-832-9668
  • Fax: 678-601-1574
Mailing address:
  • Phone: 770-258-5516
  • Fax: 770-258-5517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014278
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: