Healthcare Provider Details

I. General information

NPI: 1518537992
Provider Name (Legal Business Name): NOVUS ORTHODONTICS OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 06/29/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HENDERSON DR STE 205
CARTERSVILLE GA
30120-3756
US

IV. Provider business mailing address

650 HENDERSON DR STE 205
CARTERSVILLE GA
30120-3756
US

V. Phone/Fax

Practice location:
  • Phone: 770-387-4533
  • Fax: 770-387-4531
Mailing address:
  • Phone: 770-387-4533
  • Fax: 770-387-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNI SNOW
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 678-986-7116