Healthcare Provider Details

I. General information

NPI: 1821259854
Provider Name (Legal Business Name): GWINNETT GENERAL DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 FIVE FORKS TRICKUM RD SW SUITE 201
LILBURN GA
30047-1890
US

IV. Provider business mailing address

3100 FIVE FORKS TRICKUM RD SW SUITE 201
LILBURN GA
30047-1890
US

V. Phone/Fax

Practice location:
  • Phone: 770-978-3292
  • Fax:
Mailing address:
  • Phone: 770-978-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011818
License Number StateGA

VIII. Authorized Official

Name: DONNA LONG
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-978-3292