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General NPI Number Information
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NPI Number | 1063378966
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Entity Type | Organization
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Legal Business Name | SOUTHEAST ORAL DIAGNOSTICS LLC
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Dates
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Enumeration Date | 01/05/2026
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Last Update Date | 01/05/2026
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Provider Practice Location Address
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Address Line | 282 RUCKER RD STE 110
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City | ALPHARETTA
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State | GA
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Zip | 30004-5826
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Country | US
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Telephone | 770-992-4844
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Fax |
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Provider Business Mailing Address
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Address Line | 346 PRESTON AVE
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City | LEXINGTON
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State | KY
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Zip | 40502-1532
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Country | US
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Telephone | 770-992-4844
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Fax |
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Authorized Official
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Title or Position | OWNER/ DENTIST
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Name | DR. STEPHANIE WETZEL
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Credential |
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Telephone | 770-992-4844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number |
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License Number State |
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