MEDICARE: LOGANVILLE FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1033344650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGANVILLE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	3973 ATLANTA HWY
Second Line	:	SUITE 100
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3752
Country	:	US
Telephone Number	:	770-466-3114
Fax Number	:	770-466-3777

Provider Business Practice Location Address
First Line	:	3973 ATLANTA HWY
Second Line	:	SUITE 100
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3752
Country	:	US
Telephone Number	:	770-466-3114
Fax Number	:	770-466-3777

Authorized Official
Title or Position	:	DMD / OWNER
Name	:	DR. PONNIE D POISAL
Credential	:
Telephone Number	:	770-466-3114

Provider Enumeration Date	:	05/27/2009
Last Update Date	:	05/27/2009

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