MEDICARE: AV DENTAL CARE, 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	1223G0001X	General Practice Dentistry	DN012273	GA

General Provider Information

NPI Number	:	1922139567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AV DENTAL CARE, PC

Provider Business Mailing Address
First Line	:	3273 SHALLOWFORD RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-3632
Country	:	US
Telephone Number	:	770-455-0628
Fax Number	:	770-451-7521

Provider Business Practice Location Address
First Line	:	3273 SHALLOWFORD RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-3632
Country	:	US
Telephone Number	:	770-455-0628
Fax Number	:	770-451-7521

Authorized Official
Title or Position	:	CEO
Name	:	DR. JAYA VALLABHANENI
Credential	:	D.D.S.,
Telephone Number	:	770-455-0628

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	08/22/2020

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