Healthcare Provider Details

I. General information

NPI: 1972687903
Provider Name (Legal Business Name): CRESTON DENTAL-1, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 N MAIN ST
ANDERSON SC
29621-2763
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6407
US

V. Phone/Fax

Practice location:
  • Phone: 678-904-5665
  • Fax: 678-904-5669
Mailing address:
  • Phone: 770-916-5036
  • Fax: 678-285-4760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. TU TRAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 770-916-9000