Healthcare Provider Details

I. General information

NPI: 1881868727
Provider Name (Legal Business Name): INTERNATIONAL FAMILY DENTAL CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 JIMMY CARTER BLVD STE A14
NORCROSS GA
30093-1518
US

IV. Provider business mailing address

5495 JIMMY CARTER BLVD STE A14
NORCROSS GA
30093-1518
US

V. Phone/Fax

Practice location:
  • Phone: 770-368-9159
  • Fax: 770-368-9119
Mailing address:
  • Phone: 770-368-9159
  • Fax: 770-368-9119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11792
License Number StateGA

VIII. Authorized Official

Name: MR. JAMES WILKINS SR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-368-9159