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General NPI Number Information
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NPI Number | 1619638814
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Entity Type | Organization
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Legal Business Name | CENTER FOR COSMETIC AND SEDATION DENTISTRY JOHNS CREEK, LLC
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Dates
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Enumeration Date | 01/10/2022
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Last Update Date | 03/06/2023
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Provider Practice Location Address
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Address Line | 3440 OLD ALABAMA RD
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City | JOHNS CREEK
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State | GA
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Zip | 30022-5525
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Country | US
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Telephone | 770-475-0603
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Fax | 770-753-8893
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Provider Business Mailing Address
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Address Line | 3440 OLD ALABAMA RD
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City | JOHNS CREEK
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State | GA
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Zip | 30022-5525
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | INSURANCE MANAGER
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Name | DONNA TIDWELL
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Credential |
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Telephone | 770-995-1957
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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