Healthcare Provider Details

I. General information

NPI: 1104167865
Provider Name (Legal Business Name): GWINNETT FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 INDIAN TRAIL LILBURN RD NW SUITE 100
LILBURN GA
30047-3720
US

IV. Provider business mailing address

504 INDIAN TRAIL LILBURN RD NW SUITE 100
LILBURN GA
30047-3720
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-5100
  • Fax:
Mailing address:
  • Phone: 770-921-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateGA

VIII. Authorized Official

Name: CARLOS FERNANDO BARRIONUEVO
Title or Position: CEO
Credential:
Phone: 770-921-5100