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General NPI Number Information
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NPI Number | 1932461860
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Entity Type | Organization
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Legal Business Name | SACRED DENTAL
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Dates
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Enumeration Date | 06/15/2012
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Last Update Date | 06/15/2012
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Provider Practice Location Address
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Address Line | 1360 DOGWOOD DRIVE
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City | CONYERS
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State | GA
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Zip | 30013
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Country | US
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Telephone | 770-474-9202
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Fax |
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Provider Business Mailing Address
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Address Line | 1360 DOGWOOD DR SE
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City | CONYERS
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State | GA
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Zip | 30013-5075
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Country | US
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Telephone | 770-474-9202
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Fax | 770-474-9842
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Authorized Official
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Title or Position | DENTIST
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Name | DR. AGATHA NWIZU
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Credential |
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Telephone | 770-474-9202
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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 | DN013176
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License Number State | GA
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