MEDICARE: LRDJ 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	305R00000X	Preferred Provider Organization	DN014757	GA

General Provider Information

NPI Number	:	1578003349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LRDJ LLC

Provider Business Mailing Address
First Line	:	60 CARRIAGE OAKS DR
Second Line	:
City	:	TYRONE
State	:	GA
Zip	:	30290-1684
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 HUFF RD NW APT 4055
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4373
Country	:	US
Telephone Number	:	301-674-8761
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST/CEO
Name	:	DR. JULIAN STEWART
Credential	:	D.D.S
Telephone Number	:	301-674-8761

Provider Enumeration Date	:	02/27/2017
Last Update Date	:	02/27/2017

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