1780456301 NPI number — TOWN DENTISTRY BROOKHAVEN, LLC

Table of content: DR. LOGAN GRANT GALBRAITH MD (NPI 1720881386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780456301 NPI number — TOWN DENTISTRY BROOKHAVEN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOWN DENTISTRY BROOKHAVEN, LLC
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:
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:
1780456301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 TOWN BLVD NE STE 2010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30319-3147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-631-6277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 TOWN BLVD NE STE 2010
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKHAVEN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30319-3147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-631-6277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2023

Additional Information

Authorized Official

Authorized Official Last Name:
FRODGE
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-476-0814

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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