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General NPI Number Information
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NPI Number | 1598067993
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Entity Type | Organization
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Legal Business Name | GRAYSON PEDIATRIC DENTISTRY, P.C.
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Dates
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Enumeration Date | 11/17/2010
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Last Update Date | 11/17/2010
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Provider Practice Location Address
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Address Line | 2594 LOGANVILLE HWY SUITE 106
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City | GRAYSON
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State | GA
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Zip | 30017-7848
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Country | US
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Telephone | 678-682-9819
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Fax |
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Provider Business Mailing Address
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Address Line | 12792 WATERSIDE DR
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City | ALPHARETTA
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State | GA
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Zip | 30004-7338
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Country | US
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Telephone | 678-613-5095
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ASHA YAMINI PONUGOTI
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Credential | D.D.S.
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Telephone | 678-613-5095
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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 | DN013843
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License Number State | GA
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