MEDICARE: PRINCETON DENTAL GROUP-LOGANVILLE

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	DN011481	GA

General Provider Information

NPI Number	:	1275810129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCETON DENTAL GROUP-LOGANVILLE

Provider Business Mailing Address
First Line	:	1515 WATER SHINE WAY
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078
Country	:	US
Telephone Number	:	404-324-2012
Fax Number	:	678-344-4642

Provider Business Practice Location Address
First Line	:	4353 ATLANTA HWY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3214
Country	:	US
Telephone Number	:	770-554-0848
Fax Number	:	770-554-4569

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. KEVIN BLAIR
Credential	:
Telephone Number	:	404-324-2012

Provider Enumeration Date	:	11/07/2011
Last Update Date	:	09/28/2014

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