MEDICARE: HAVEN DENTAL CARE GROUP 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952008179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN DENTAL CARE GROUP LLC

Provider Business Mailing Address
First Line	:	3312 PEACHTREE INDUSTRIAL BLVD STE 8
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-8100
Country	:	US
Telephone Number	:	770-545-8647
Fax Number	:

Provider Business Practice Location Address
First Line	:	3312 PEACHTREE INDUSTRIAL BLVD STE 8
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-8100
Country	:	US
Telephone Number	:	770-545-8647
Fax Number	:	770-545-8648

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. THOMAS T LEE
Credential	:	DDS
Telephone Number	:	770-624-4912

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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