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General NPI Number Information
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NPI Number | 1003280595
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Entity Type | Organization
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Legal Business Name | LAWRENCEVILLE FAMILY DENTISTRY
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Dates
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Enumeration Date | 11/20/2015
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Last Update Date | 11/20/2015
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Provider Practice Location Address
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Address Line | 3664 CLUB DR STE 105
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-2961
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Country | US
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Telephone | 770-279-7987
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Fax | 770-279-8951
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Provider Business Mailing Address
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Address Line | 3664 CLUB DR STE 105
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-2961
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Country | US
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Telephone | 770-279-7987
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Fax | 770-279-8951
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. NAYEEM BASHAR
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Credential | DDS
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Telephone | 770-279-7987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN012875
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License Number State | GA
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