=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023670320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMI PARK DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 09/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 19TH ST NW STE 7200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30363-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-567-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2137 BURNSIDE DR NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-5861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-267-6483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN015839
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------