Healthcare Provider Details

I. General information

NPI: 1861736514
Provider Name (Legal Business Name): SENOIA FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 MAIN ST SUITE 3B
SENOIA GA
30276-1889
US

IV. Provider business mailing address

42 MAIN ST SUITE 3B
SENOIA GA
30276-1889
US

V. Phone/Fax

Practice location:
  • Phone: 770-599-4441
  • Fax: 770-599-4442
Mailing address:
  • Phone: 770-599-4441
  • Fax: 770-599-4442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN012726
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN012740
License Number StateGA

VIII. Authorized Official

Name: DR. RAGAN FALER
Title or Position: OWNER
Credential: DMD
Phone: 678-289-0382