MEDICARE: DULUTH DENTAL CLUB, PC

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

General Provider Information

NPI Number	:	1235726795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DULUTH DENTAL CLUB, PC

Provider Business Mailing Address
First Line	:	2151 HUNTERS GREEN DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-5181
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 PEACHTREE INDUSTRIAL BLVD STE 202
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-8628
Country	:	US
Telephone Number	:	678-385-9355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PARTH PATEL
Credential	:	DMD
Telephone Number	:	215-692-2993

Provider Enumeration Date	:	12/30/2020
Last Update Date	:	12/01/2021

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