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General NPI Number Information
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NPI Number | 1205591526
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Entity Type | Organization
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Legal Business Name | MAHANT DENTAL LLC
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Dates
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Enumeration Date | 11/02/2021
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Last Update Date | 11/02/2021
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Provider Practice Location Address
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Address Line | 5396 FLOYD RD SW
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City | MABLETON
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State | GA
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Zip | 30126-2216
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Country | US
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Telephone | 770-941-7588
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Fax | 770-941-2119
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Provider Business Mailing Address
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Address Line | 1411 CROMWELL DR APT SUITE
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City | TARPON SPRINGS
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State | FL
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Zip | 34689-3017
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Country | US
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Telephone | 727-686-3773
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Fax |
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Authorized Official
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Title or Position | INSURANCE ADMINISTRATOR
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Name | KELLEY HALVORSEN
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Credential |
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Telephone | 727-686-3773
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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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