Healthcare Provider Details

I. General information

NPI: 1720990476
Provider Name (Legal Business Name): GWINNETT DENTAL STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 HIGHLAND STATION DR STE 1006
SUWANEE GA
30024-6572
US

IV. Provider business mailing address

530 HIGHLAND STATION DR STE 1006
SUWANEE GA
30024-6572
US

V. Phone/Fax

Practice location:
  • Phone: 470-563-7111
  • Fax:
Mailing address:
  • Phone: 470-563-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TITUS WONGK
Title or Position: DENTIST
Credential: DMD
Phone: 470-563-7111