1801292750 NPI number — IMPLANT AND AESTHETIC SPECIALISTS OF ATLANTA

Table of content: (NPI 1801292750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801292750 NPI number — IMPLANT AND AESTHETIC SPECIALISTS OF ATLANTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPLANT AND AESTHETIC SPECIALISTS OF ATLANTA
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:
BRETT R. LANGSTON, D.M.D.
Provider Other Organization Name Type Code:
3
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:
1801292750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1991 N WILLIAMSBURG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-321-4588
Provider Business Mailing Address Fax Number:
404-321-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1991 N WILLIAMSBURG DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-321-4588
Provider Business Practice Location Address Fax Number:
404-321-1892
Provider Enumeration Date:
11/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LANGSTON
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-321-4588

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN013111 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X , with the licence number: DN013111 , 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)





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