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General NPI Number Information
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NPI Number | 1134372279
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Entity Type | Organization
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Legal Business Name | METRO DEKALB DENTAL GROUP
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Dates
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Enumeration Date | 11/03/2008
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Last Update Date | 11/03/2008
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Provider Practice Location Address
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Address Line | 4849 MEMORIAL DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4175
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Country | US
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Telephone | 404-296-4119
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Fax | 404-935-0905
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Provider Business Mailing Address
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Address Line | 4849 MEMORIAL DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4175
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Country | US
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Telephone | 404-296-4119
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Fax | 404-935-0905
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Authorized Official
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Title or Position | DENTIST
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Name | GARY SIMMS
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Credential | D.M.D.
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Telephone | 404-296-4119
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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 | DN013291
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License Number State | GA
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