=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568633311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL DENTAL MANAGEMENT SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 03/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 HAMMOND DR NE C-3120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-604-9944
-----------------------------------------------------
Fax | 770-604-9945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 HAMMOND DR NE C-3120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-604-9944
-----------------------------------------------------
Fax | 770-604-9945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. LARRY BUFORD
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 770-604-9944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------