Healthcare Provider Details

I. General information

NPI: 1508954116
Provider Name (Legal Business Name): LANIER ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3444
US

IV. Provider business mailing address

1215 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3444
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-4156
  • Fax: 770-536-1529
Mailing address:
  • Phone: 770-532-4156
  • Fax: 770-536-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011899
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011067
License Number StateGA

VIII. Authorized Official

Name: KYM MADDOX
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 770-532-8104