=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699002832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL ONE ASSOCIATES DUNWOODY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 11/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901B PEACHTREE DUNWOODY RD NE # 250
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-698-9133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901B PEACHTREE DUNWOODY RD NE # 250
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE DIRECTOR
-----------------------------------------------------
Name | MICHAEL COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-726-1611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 012064
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------