=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295218881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL NATION PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2018
-----------------------------------------------------
Last Update Date | 09/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4343 S MAIN ST
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-644-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 589 AUBURN AVE NE UNIT A
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-1990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-644-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | YEN TRAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 404-644-5963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------