Healthcare Provider Details

I. General information

NPI: 1891915633
Provider Name (Legal Business Name): DAWN M ROSALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 BEAVER RUIN RD NW STE A
LILBURN GA
30047-3401
US

IV. Provider business mailing address

403 PUCKETT TER SW
LILBURN GA
30047-4053
US

V. Phone/Fax

Practice location:
  • Phone: 770-925-3300
  • Fax: 770-925-3302
Mailing address:
  • Phone: 770-931-1924
  • Fax: 678-990-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: