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General NPI Number Information
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NPI Number | 1457793895
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Entity Type | Organization
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Legal Business Name | AESTHETIC DENTAL ASSOC OF NE GA LLC
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Dates
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Enumeration Date | 07/26/2013
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Last Update Date | 07/26/2013
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Provider Practice Location Address
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Address Line | 1520A JENNINGS MILL RD
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City | BOGART
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State | GA
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Zip | 30622-2543
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Country | US
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Telephone | 706-353-1958
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Fax | 706-353-3939
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Provider Business Mailing Address
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Address Line | 1520A JENNINGS MILL RD
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City | BOGART
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State | GA
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Zip | 30622-2543
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Country | US
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Telephone | 706-353-1958
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Fax | 706-353-3939
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Authorized Official
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Title or Position | OWNER
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Name | R. LAWRENCE GEORGE
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Credential | DMD
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Telephone | 706-353-1958
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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 | DN007721
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License Number State | GA
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