Healthcare Provider Details

I. General information

NPI: 1699325506
Provider Name (Legal Business Name): DENTAL HOME ATLANTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3796 SATELLITE BLVD SUITE #100
DULUTH GA
30096
US

IV. Provider business mailing address

3796 SATELLITE BLVD SUITE #100
DULUTH GA
30096
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-4140
  • Fax: 404-900-1924
Mailing address:
  • Phone: 770-476-4140
  • Fax: 404-900-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: HEN CHEN
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 770-476-4140