=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467634741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCEVILLE DENTAL ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2007
-----------------------------------------------------
Last Update Date | 12/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 GWINNETT DRIVE, SUITE C
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-913-1941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 999 PEACHTREE STREET, NE SUITE 800
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-537-5211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENNETHE TRALONGO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 404-537-5211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0011999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------