Healthcare Provider Details

I. General information

NPI: 1689961229
Provider Name (Legal Business Name): ATLANTA ENDODONTIC GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2011
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 HWY 20 W SUITE 200
MCDONOUGH GA
30253
US

IV. Provider business mailing address

1705 HWY 20 W SUITE 200
MCDONOUGH GA
30253
US

V. Phone/Fax

Practice location:
  • Phone: 770-954-8672
  • Fax: 770-954-0074
Mailing address:
  • Phone: 770-954-0072
  • Fax: 770-954-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN013945
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ROLIN DESIR
Title or Position: ENDODONTIST / OWNER
Credential: DDS
Phone: 770-954-0072