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General NPI Number Information
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NPI Number | 1356105423
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY DENTISTRY, P.C.
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Dates
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Enumeration Date | 02/09/2024
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Last Update Date | 02/09/2024
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Provider Practice Location Address
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Address Line | 224 SHALLOWFORD RD NW
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City | GAINESVILLE
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State | GA
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Zip | 30504-4171
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Country | US
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Telephone | 770-536-1170
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Fax |
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Provider Business Mailing Address
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Address Line | 224 SHALLOWFORD RD NW
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City | GAINESVILLE
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State | GA
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Zip | 30504-4171
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | BEN CUTLER
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Credential |
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Telephone | 607-743-9474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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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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