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General NPI Number Information
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NPI Number | 1811024078
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Entity Type | Organization
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Legal Business Name | IVY DENTISTRY LLC
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 12/21/2007
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Provider Practice Location Address
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Address Line | 11775 NORTHFALL LN
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City | ALPHARETTA
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State | GA
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Zip | 30004-7978
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Country | US
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Telephone | 770-619-2909
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Fax | 770-619-2939
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Provider Business Mailing Address
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Address Line | PO BOX 80097
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City | CHAMBLEE
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State | GA
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Zip | 30366-0097
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Country | US
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Telephone | 770-619-2909
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Fax | 770-619-2939
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ERIN BANG
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Credential | DDS
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Telephone | 770-619-2909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN011829
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License Number State | GA
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