Healthcare Provider Details

I. General information

NPI: 1356149546
Provider Name (Legal Business Name): CHATTAHOOCHEE FAMILY ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 MEDICAL PARK DR STE B
GAINESVILLE GA
30501-2055
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 470-613-1649
  • Fax:
Mailing address:
  • Phone: 727-784-2721
  • 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: NICOLE CARIDE
Title or Position: CREDENTIALING MGR
Credential:
Phone: 727-784-2721