=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154688471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADRIENNE EMBRY AMMONS, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2012
-----------------------------------------------------
Last Update Date | 04/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11349 TARA BLVD
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-6261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-964-2148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11349 TARA BLVD
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-6261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. ADRIENNE EMBRY AMMONS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 678-964-2148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN013238
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------