Healthcare Provider Details

I. General information

NPI: 1316245814
Provider Name (Legal Business Name): SYLVESTER CARLO III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 PAVILION CT
MCDONOUGH GA
30253-6665
US

IV. Provider business mailing address

1740 HUDSON BRIDGE RD SUITE 1222
STOCKBRIDGE GA
30281-6331
US

V. Phone/Fax

Practice location:
  • Phone: 404-536-4322
  • Fax: 770-474-4477
Mailing address:
  • Phone: 404-536-4322
  • Fax: 770-474-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN012125
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: