MEDICARE: MOUNT VERNON DENTAL GROUP, 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	122300000X	Dentist

General Provider Information

NPI Number	:	1528665486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT VERNON DENTAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2472 JETT FERRY RD STE 430
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-3059
Country	:	US
Telephone Number	:	770-396-8061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2472 JETT FERRY RD STE 430
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-3059
Country	:	US
Telephone Number	:	770-396-8061
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DOMINICK M D'AURIA
Credential	:	DDS
Telephone Number	:	770-722-5000

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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