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General NPI Number Information
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NPI Number | 1174868905
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Entity Type | Organization
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Legal Business Name | MIDTOWN DENTAL STUDIO LLC
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Dates
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Enumeration Date | 12/05/2012
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Last Update Date | 12/05/2012
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Provider Practice Location Address
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Address Line | 197 14TH ST NW SUITE 101
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City | ATLANTA
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State | GA
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Zip | 30318-7815
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Country | US
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Telephone | 404-937-6940
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Fax |
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Provider Business Mailing Address
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Address Line | 197 14TH ST NW SUITE 101
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City | ATLANTA
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State | GA
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Zip | 30318-7815
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Country | US
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Telephone | 404-937-6940
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Fax |
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Authorized Official
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Title or Position | CEO/DENTIST
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Name | DR. TRAVON J HOLT
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Credential |
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Telephone | 404-937-6940
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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 |
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License Number State |
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