MEDICARE: EAST 53RD STREET DENTAL-3, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1780983726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST 53RD STREET DENTAL-3, PC

Provider Business Mailing Address
First Line	:	210 INTERSTATE NORTH PKWY SE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2233
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:	678-247-7858

Provider Business Practice Location Address
First Line	:	4315 COMMERCE DR
Second Line	:	SUITE 310
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-3822
Country	:	US
Telephone Number	:	678-904-5665
Fax Number	:	678-904-5666

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER IGOE
Credential	:	DMD
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	04/24/2026

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