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General NPI Number Information
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NPI Number | 1215235726
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Entity Type | Organization
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Legal Business Name | FREEDOM 11, LLC
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Dates
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Enumeration Date | 03/08/2011
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Last Update Date | 03/08/2011
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Provider Practice Location Address
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Address Line | 3840 PEACHTREE INDUSTRIAL BLVD 320
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City | DULUTH
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State | GA
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Zip | 30096
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Country | US
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Telephone | 770-670-6555
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Fax |
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Provider Business Mailing Address
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Address Line | 3840 PEACHTREE INDUSTRIAL BLVD 320
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City | DULUTH
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State | GA
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Zip | 30096
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Country | US
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Telephone | 770-670-6555
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL REZNIK
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Credential |
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Telephone | 404-307-0358
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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 | 8077
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License Number State | GA
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