=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508085671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLD MILTON DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4165 OLD MILTON PKWY SUITE 190
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-4468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-624-0370
-----------------------------------------------------
Fax | 678-624-0319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4165 OLD MILTON PKWY SUITE 190
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-4468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-624-0370
-----------------------------------------------------
Fax | 678-624-0319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. COREY J MAZER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 678-624-0370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 012301
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 012287
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------