1699325506 NPI number — DENTAL HOME ATLANTA

Table of content: (NPI 1699325506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699325506 NPI number — DENTAL HOME ATLANTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL HOME 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:
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:
1699325506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3796 SATELLITE BLVD
Provider Second Line Business Mailing Address:
SUITE #100
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-476-4140
Provider Business Mailing Address Fax Number:
404-900-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3796 SATELLITE BLVD
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-476-4140
Provider Business Practice Location Address Fax Number:
404-900-1924
Provider Enumeration Date:
09/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CHEN
Authorized Official First Name:
HEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
770-476-4140

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003220690A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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