Healthcare Provider Details

I. General information

NPI: 1245507292
Provider Name (Legal Business Name): EAGLIN DENTAL GROUP, JOHNS CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6290 ABBOTTS BRIDGE RD STE 101
JOHNS CREEK GA
30097-1750
US

IV. Provider business mailing address

6290 ABBOTTS BRIDGE RD STE 101
JOHNS CREEK GA
30097-1750
US

V. Phone/Fax

Practice location:
  • Phone: 770-418-1777
  • Fax: 678-646-5982
Mailing address:
  • Phone: 770-418-1777
  • Fax: 678-646-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013169
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013169
License Number StateGA

VIII. Authorized Official

Name: DR. JASON S EAGLIN
Title or Position: OWNER
Credential: DDS
Phone: 770-418-1777