MEDICARE: NORTH ROBERTS ROAD DENTAL GROUP

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	:	1346389863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH ROBERTS ROAD DENTAL GROUP

Provider Business Mailing Address
First Line	:	1301 SHILOH RD NW
Second Line	:	BLD 600 SUITE 660
City	:	KENNESAW
State	:	GA
Zip	:	30144-7147
Country	:	US
Telephone Number	:	770-423-9699
Fax Number	:	850-837-7448

Provider Business Practice Location Address
First Line	:	1301 SHILOH RD NW
Second Line	:	BLD 600 SUITE 660
City	:	KENNESAW
State	:	GA
Zip	:	30144-7147
Country	:	US
Telephone Number	:	770-423-9699
Fax Number	:	850-837-7448

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	VENICIA HENRY
Credential	:
Telephone Number	:	770-423-9699

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	08/22/2020

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