Healthcare Provider Details

I. General information

NPI: 1396979316
Provider Name (Legal Business Name): ORTHODONTIC CARE OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 STONECREST CONC SUITE 115
LITHONIA GA
30038-6901
US

IV. Provider business mailing address

1828 JONESBORO RD
MCDONOUGH GA
30253-5960
US

V. Phone/Fax

Practice location:
  • Phone: 770-482-4885
  • Fax: 770-482-4631
Mailing address:
  • Phone: 678-432-8505
  • Fax: 678-432-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number011309
License Number StateGA

VIII. Authorized Official

Name: ROBERT ZAYAS
Title or Position: MANAGER
Credential:
Phone: 706-342-7272