Healthcare Provider Details

I. General information

NPI: 1497086367
Provider Name (Legal Business Name): WINDERMERE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2010
Last Update Date: 01/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 MATHIS AIRPORT PKWY SUITE 106
SUWANEE GA
30024-9128
US

IV. Provider business mailing address

3120 MATHIS AIRPORT PKWY SUITE 106
SUWANEE GA
30024-9128
US

V. Phone/Fax

Practice location:
  • Phone: 770-888-1929
  • Fax: 770-888-1859
Mailing address:
  • Phone: 770-888-1929
  • Fax: 770-888-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013818
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL L GORLOVSKY
Title or Position: OWNER
Credential: DMD, MS
Phone: 770-888-1929