Healthcare Provider Details

I. General information

NPI: 1174717086
Provider Name (Legal Business Name): LEROY OLUFEMI VENN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5370 CAMPBELLTON FAIRBURN RD SUITE 430
FAIRBURN GA
30213-2296
US

IV. Provider business mailing address

PO BOX 250053
ATLANTA GA
30325-1053
US

V. Phone/Fax

Practice location:
  • Phone: 770-892-3833
  • Fax: 770-892-3836
Mailing address:
  • Phone: 770-892-3833
  • Fax: 770-892-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013078
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: