Healthcare Provider Details

I. General information

NPI: 1427327923
Provider Name (Legal Business Name): PEARLS OF HEALTH MEDICAL AND DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7580 SPRINGBOX DR SUITE 250
FAIRBURN GA
30213-1287
US

IV. Provider business mailing address

7580 SPRINGBOX DR SUITE 250
FAIRBURN GA
30213-1287
US

V. Phone/Fax

Practice location:
  • Phone: 770-306-4457
  • Fax: 770-774-7218
Mailing address:
  • Phone: 770-306-4457
  • Fax: 770-774-7218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE KAREN NICOME
Title or Position: MEMBER/MANAGER
Credential: MD
Phone: 770-306-4457