Healthcare Provider Details

I. General information

NPI: 1316202872
Provider Name (Legal Business Name): ZOOM DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4574 LAWRENCEVILLE HWY NW STE 120
LILBURN GA
30047-3605
US

IV. Provider business mailing address

4574 LAWRENCEVILLE HWY NW STE 120
LILBURN GA
30047-3605
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-9000
  • Fax: 770-931-7704
Mailing address:
  • Phone: 770-921-9000
  • Fax: 770-931-7704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN014407
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013700
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013014
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10984
License Number StateGA

VIII. Authorized Official

Name: DR. ANNE NA
Title or Position: DENTIST
Credential:
Phone: 770-921-9000