Healthcare Provider Details

I. General information

NPI: 1508038076
Provider Name (Legal Business Name): FABULOUS DENTISTRY AND ORTHODONTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 INDIAN TRL RD NW SUITE 3-G
LILBURN GA
30047-1721
US

IV. Provider business mailing address

950 INDIAN TRL RD NW SUITE 3-G
LILBURN GA
30047-1721
US

V. Phone/Fax

Practice location:
  • Phone: 678-325-3970
  • Fax: 678-325-3971
Mailing address:
  • Phone: 678-325-3970
  • Fax: 678-325-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN J SOLANO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 678-325-3970