MEDICARE: DENTISTRY FOR MIDTOWN, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1730591603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRY FOR MIDTOWN, LLC

Provider Business Mailing Address
First Line	:	1401 PEACHTREE ST NE STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-3005
Country	:	US
Telephone Number	:	404-249-1716
Fax Number	:	404-249-1716

Provider Business Practice Location Address
First Line	:	1401 PEACHTREE ST NE STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-3005
Country	:	US
Telephone Number	:	404-249-1716
Fax Number	:	404-249-8057

Authorized Official
Title or Position	:	OWNER
Name	:	LAURA C KOCH
Credential	:	DMD
Telephone Number	:	404-249-1716

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	01/10/2023

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