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General NPI Number Information
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NPI Number | 1154069391
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Entity Type | Organization
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Legal Business Name | BENTWATER COSMETIC AND FAMILY DENTISTRY
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 07/27/2022
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Provider Practice Location Address
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Address Line | 351 THORNTON RD STE 101
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-1589
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Country | US
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Telephone | 770-944-9755
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Fax | 770-944-1261
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Provider Business Mailing Address
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Address Line | 351 THORNTON RD STE 101
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-1589
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Country | US
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Telephone | 770-944-9755
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Fax | 770-944-1261
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | TIFFANY THRELKELD
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Credential | DO
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Telephone | 678-499-3514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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