=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083338685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOCD LAWRENCEVILLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2022
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2087 CRUSE RD STE B
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-845-2424
-----------------------------------------------------
Fax | 706-558-3909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2087 CRUSE RD STE B
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-845-2424
-----------------------------------------------------
Fax | 706-558-3909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. JUSTIN CHONG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 770-854-2424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------