MEDICARE: GWINNETT DENTAL CARE LAWRENCEVILLE LLC

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	:	1235875295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT DENTAL CARE LAWRENCEVILLE LLC

Provider Business Mailing Address
First Line	:	301 PAPER WOODS DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-5366
Country	:	US
Telephone Number	:	678-520-7534
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 DULUTH HWY STE E2
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-5399
Country	:	US
Telephone Number	:	678-520-7534
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. LONG PHUNG
Credential	:	DMD
Telephone Number	:	678-520-7534

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	05/11/2022

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