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General NPI Number Information
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NPI Number | 1306414537
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Entity Type | Individual
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Provider Name | MUKTI GUNVANT PREMA DDS
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Gender | Female
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Dates
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Enumeration Date | 06/14/2021
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 2101 BAKER CARTER DR STE 200
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City | LOGANVILLE
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State | GA
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Zip | 30052-7466
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Country | US
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Telephone | 678-661-5161
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Fax |
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Provider Business Mailing Address
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Address Line | 5461 OAK CHASE DR
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City | ANTIOCH
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State | TN
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Zip | 37013-4250
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Country | US
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Telephone | 615-612-8985
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN122875
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License Number State | GA
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