Healthcare Provider Details

I. General information

NPI: 1316112360
Provider Name (Legal Business Name): GWINNETT FAMILY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-4101
US

IV. Provider business mailing address

3455 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-4101
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-1115
  • Fax: 770-564-3856
Mailing address:
  • Phone: 770-921-1115
  • Fax: 770-564-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberGA11839
License Number StateGA

VIII. Authorized Official

Name: DR. KELL D. GALLAHER
Title or Position: OWNER
Credential: DMD
Phone: 770-921-1115