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General NPI Number Information
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NPI Number | 1538506720
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF JOHNS CREEK, LLC
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Dates
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Enumeration Date | 05/28/2013
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Last Update Date | 05/28/2013
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Provider Practice Location Address
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Address Line | 10475 MEDLOCK BRIDGE RD 501
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City | JOHNS CREEK
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State | GA
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Zip | 30097-4433
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Country | US
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Telephone | 678-822-9818
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Fax | 678-822-9820
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Provider Business Mailing Address
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Address Line | 10475 MEDLOCK BRIDGE RD 501
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City | JOHNS CREEK
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State | GA
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Zip | 30097-4433
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Country | US
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Telephone | 678-822-9818
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Fax |
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Authorized Official
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Title or Position | OWERN/DENTIST
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Name | JAMES HICKS
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Credential | DMD
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Telephone | 678-822-9818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN013896
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License Number State | GA
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