Healthcare Provider Details

I. General information

NPI: 1235875295
Provider Name (Legal Business Name): GWINNETT DENTAL CARE LAWRENCEVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 DULUTH HWY STE E2
LAWRENCEVILLE GA
30043-5399
US

IV. Provider business mailing address

301 PAPER WOODS DR
LAWRENCEVILLE GA
30046-5366
US

V. Phone/Fax

Practice location:
  • Phone: 678-520-7534
  • Fax:
Mailing address:
  • Phone: 678-520-7534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LONG PHUNG
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 678-520-7534