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General NPI Number Information
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NPI Number | 1235875295
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Entity Type | Organization
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Legal Business Name | GWINNETT DENTAL CARE LAWRENCEVILLE LLC
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Dates
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Enumeration Date | 05/11/2022
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Last Update Date | 05/11/2022
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Provider Practice Location Address
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Address Line | 911 DULUTH HWY STE E2
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5399
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Country | US
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Telephone | 678-520-7534
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Fax |
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Provider Business Mailing Address
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Address Line | 301 PAPER WOODS DR
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-5366
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Country | US
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Telephone | 678-520-7534
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. LONG PHUNG
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Credential | DMD
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Telephone | 678-520-7534
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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