Healthcare Provider Details

I. General information

NPI: 1285077933
Provider Name (Legal Business Name): GWINNETT PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 LAWRENCEVILLE SUWANEE RD SUITE D
SUWANEE GA
30024-2535
US

IV. Provider business mailing address

2594 LOGANVILLE HWY SUITE 106
GRAYSON GA
30017-7848
US

V. Phone/Fax

Practice location:
  • Phone: 678-799-7675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013843
License Number StateGA

VIII. Authorized Official

Name: DR. ASHA YAMINI PONUGOTI
Title or Position: OWNER
Credential: D.D.S.
Phone: 678-613-5095