Healthcare Provider Details

I. General information

NPI: 1356975098
Provider Name (Legal Business Name): GWINNETT ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 KILLIAN HILL RD SW STE D
LILBURN GA
30047-8977
US

IV. Provider business mailing address

956 KILLIAN HILL RD SW STE D
LILBURN GA
30047-8977
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-2233
  • Fax: 770-921-6090
Mailing address:
  • Phone: 770-921-2233
  • Fax: 770-921-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JANICE J WILMOT
Title or Position: OWNER/ORTHODONTIST
Credential: DMD, MS
Phone: 770-921-2233