Healthcare Provider Details

I. General information

NPI: 1740649177
Provider Name (Legal Business Name): ICLEAR ORTHODONTICS AND BRACES NORTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 PEACHTREE PKWY SUITE 200
NORCROSS GA
30092-2879
US

IV. Provider business mailing address

5635 PEACHTREE PKWY SUITE 200
NORCROSS GA
30092-2879
US

V. Phone/Fax

Practice location:
  • Phone: 770-448-0494
  • Fax:
Mailing address:
  • Phone: 770-448-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN014522
License Number StateGA

VIII. Authorized Official

Name: KALPESHKUMAR THAKKAR
Title or Position: MANAGER
Credential: DDS
Phone: 770-448-0494