Healthcare Provider Details

I. General information

NPI: 1891239919
Provider Name (Legal Business Name): FAYETTEVILLE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N JEFF DAVIS DR SUITE C
FAYETTEVILLE GA
30214-1669
US

IV. Provider business mailing address

320 N JEFF DAVIS DR SUITE C
FAYETTEVILLE GA
30214-1669
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN04542
License Number StateGA

VIII. Authorized Official

Name: RUCHIR PATEL
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 770-460-6000