Healthcare Provider Details

I. General information

NPI: 1205167962
Provider Name (Legal Business Name): DANA E NELSON WITHERSPOON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 RIVERSIDE PARKWAY, SUITE 200 GREAT EXPRESSIONS DENTAL CENTERS OF GEORGIA, PC
LAWRENCEVILLE GA
30043
US

IV. Provider business mailing address

2000 RIVERSIDE PARKWAY, SUITE 200 GREAT EXPRESSIONS DENTAL CENTERS OF GEORGIA, PC
LAWRENCEVILLE GA
30043
US

V. Phone/Fax

Practice location:
  • Phone: 202-487-5044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013754
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8670
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number8670
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: