=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699035345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JBM-DENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2012
-----------------------------------------------------
Last Update Date | 05/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1336 GLENWOOD AVE SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-688-0013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1336 GLENWOOD AVENUE SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-688-0013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER / INS. SPECIALIST
-----------------------------------------------------
Name | MS. BARBARA ELIZABETH ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-319-7755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9493
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------