=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881811982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE E ASHENDORF D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 HENDERSON MILL RD NE SUITE 401
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30345-2745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-938-3277
-----------------------------------------------------
Fax | 770-934-1240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 730 BUTTERCUP TRCE
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-5174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-840-8883
-----------------------------------------------------
Fax | 770-934-1240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9326
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------