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General NPI Number Information
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NPI Number | 1699588178
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Entity Type | Organization
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Legal Business Name | ELITE DENTAL MANAGEMENT INC
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 06/18/2025
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Provider Practice Location Address
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Address Line | 2100 RIVERSIDE PKWY STE 130
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5914
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Country | US
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Telephone | 770-822-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 RIVERSIDE PKWY STE 130
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5914
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Country | US
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Telephone | 770-822-3400
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. CHIN PARK
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Credential | DMD
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Telephone | 770-879-1200
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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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