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General NPI Number Information
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NPI Number | 1427220458
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL GROUP PC
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Dates
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Enumeration Date | 03/31/2008
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Last Update Date | 03/31/2008
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Provider Practice Location Address
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Address Line | 848 MAIN ST
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City | FOREST PARK
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State | GA
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Zip | 30297-1465
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Country | US
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Telephone | 404-366-3724
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Fax | 404-366-4271
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Provider Business Mailing Address
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Address Line | 848 MAIN ST
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City | FOREST PARK
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State | GA
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Zip | 30297-1465
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Country | US
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Telephone | 404-366-3724
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Fax | 404-366-4271
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUAN J SOLANO
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Credential | D.D.S.
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Telephone | 404-366-3724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN012689
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License Number State | GA
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