MEDICARE: NORTHSIDE COSMETIC AND DENTAL IMPLANT CENTER, PC

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	:	1629721634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE COSMETIC AND DENTAL IMPLANT CENTER, PC

Provider Business Mailing Address
First Line	:	5555 PEACHTREE DUNWOODY RD STE 140
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-5032
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 PEACHTREE DUNWOODY RD STE 140
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-5032
Country	:	US
Telephone Number	:	678-944-9422
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KISHAN DHANANI
Credential	:
Telephone Number	:	678-944-9422

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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