=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609751346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY CAROLINE MEDENDORP DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2025
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 CORPORATE CENTER CT
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-901-2492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2344 HAVENRIDGE DR NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-4073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-606-6014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN123920
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------