Healthcare Provider Details

I. General information

NPI: 1972972685
Provider Name (Legal Business Name): TRINITY ORTHODONTICS OF FAYETTEVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 LANIER AVE W STE B
FAYETTEVILLE GA
30214-7621
US

IV. Provider business mailing address

719 LANIER AVE W STE B
FAYETTEVILLE GA
30214-7621
US

V. Phone/Fax

Practice location:
  • Phone: 404-696-6595
  • Fax:
Mailing address:
  • Phone: 404-696-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PAUL MCKOY
Title or Position: CFO
Credential: DDS
Phone: 404-696-6595