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General NPI Number Information
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NPI Number | 1710304373
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Entity Type | Organization
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Legal Business Name | SRR LLC
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Dates
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Enumeration Date | 03/20/2014
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Last Update Date | 03/21/2014
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Provider Practice Location Address
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Address Line | 114 MIRRAMONT LAKE DR
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City | WOODSTOCK
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State | GA
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Zip | 30189-8213
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Country | US
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Telephone | 770-592-7000
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Fax | 770-517-7403
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Provider Business Mailing Address
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Address Line | 114 MIRRAMONT LAKE DR
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City | WOODSTOCK
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State | GA
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Zip | 30189-8213
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Country | US
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Telephone | 770-592-7000
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Fax | 770-517-7403
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MRS. HIRAL ANKUR PATEL
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Credential | RDH
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Telephone | 706-346-9516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | LC20140000214
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License Number State | GA
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