1417283730 NPI number — THE DENTURE PLACE AT MCDONOUGH

Table of content: VIKTOR E EYSSELEIN M.D. (NPI 1609848191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417283730 NPI number — THE DENTURE PLACE AT MCDONOUGH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DENTURE PLACE AT MCDONOUGH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417283730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 DECATUR RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-2024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-957-1113
Provider Business Mailing Address Fax Number:
770-957-2182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 DECATUR RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-957-1113
Provider Business Practice Location Address Fax Number:
770-957-2182
Provider Enumeration Date:
10/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HENSON
Authorized Official First Name:
EARL
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-957-1113

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN013862 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: DN007434 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0051664G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 312341163B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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