MEDICARE: BUCKHEAD PERIODONTICS, P.C.

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	261QD0000X	Dental Clinic/Center	DN009901	GA

General Provider Information

NPI Number	:	1093990327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKHEAD PERIODONTICS, P.C.

Provider Business Mailing Address
First Line	:	2970 PEACHTREE RD NW
Second Line	:	SUITE #622
City	:	ATLANTA
State	:	GA
Zip	:	30305-2192
Country	:	US
Telephone Number	:	404-261-9593
Fax Number	:	404-261-9409

Provider Business Practice Location Address
First Line	:	2970 PEACHTREE RD NW
Second Line	:	SUITE #622
City	:	ATLANTA
State	:	GA
Zip	:	30305-2192
Country	:	US
Telephone Number	:	404-261-9593
Fax Number	:	404-261-9409

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAURA DAY BRASWELL
Credential	:	D.D.S.
Telephone Number	:	404-261-9593

Provider Enumeration Date	:	01/06/2008
Last Update Date	:	01/06/2008

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