Healthcare Provider Details

I. General information

NPI: 1033655576
Provider Name (Legal Business Name): DACULA PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2017
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 BRASELTON HWY SUITE 202
DACULA GA
30019-1014
US

IV. Provider business mailing address

3234 ISLESWORTH TRCE
DULUTH GA
30097-6288
US

V. Phone/Fax

Practice location:
  • Phone: 770-856-2363
  • Fax: 770-809-5055
Mailing address:
  • Phone: 678-417-9509
  • Fax: 770-809-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number058358
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier1629191465
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerPROVIDER NPI NUMBER
# 2
Identifier904800152B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: DR. SARVPREET KAUR
Title or Position: OWNER
Credential: MD
Phone: 678-517-5607