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General NPI Number Information
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NPI Number | 1528105491
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Entity Type | Organization
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Legal Business Name | FAYETTEVILLE DENTAL GROUP
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 141 BANKS STA SUITE 121-122
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7504
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Country | US
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Telephone | 770-716-9778
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Fax | 770-716-9075
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Provider Business Mailing Address
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Address Line | 141 BANKS STA SUITE 121-122
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7504
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Country | US
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Telephone | 770-716-9778
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Fax | 770-716-9075
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER CONSTABLE
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Credential |
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Telephone | 770-716-9778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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