MEDICARE: DULUTH 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	:	1114138039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DULUTH FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	3312 PEACHTREE INDUSTRIAL BLVD
Second Line	:	SUITE 8
City	:	DULUTH
State	:	GA
Zip	:	30096-8100
Country	:	US
Telephone Number	:	770-814-7600
Fax Number	:	770-814-0824

Provider Business Practice Location Address
First Line	:	3312 PEACHTREE INDUSTRIAL BLVD
Second Line	:	SUITE 8
City	:	DULUTH
State	:	GA
Zip	:	30096-8100
Country	:	US
Telephone Number	:	770-814-7600
Fax Number	:	770-814-0824

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MANOJ MAGGAN
Credential	:	DDS
Telephone Number	:	770-814-7600

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	08/22/2020

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