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General NPI Number Information
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NPI Number | 1689152282
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Entity Type | Organization
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Legal Business Name | EASTLIGHT DENTAL, L.L.C.
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Dates
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Enumeration Date | 08/06/2018
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Last Update Date | 09/18/2018
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Provider Practice Location Address
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Address Line | 2536 ROCKBRIDGE RD STE 103
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3636
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Country | US
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Telephone | 678-395-5913
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Fax |
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Provider Business Mailing Address
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Address Line | 2536 ROCKBRIDGE RD STE 103
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3636
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Country | US
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Telephone | 678-395-5913
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Fax | 678-395-5678
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Authorized Official
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Title or Position | OWNER
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Name | MR. EDMUND THOMAS JR.
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Credential | DDS
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Telephone | 716-949-2183
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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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