1902540669 NPI number — ASSISTED DENTAL CARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902540669 NPI number — ASSISTED DENTAL CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSISTED DENTAL CARE, 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:
1902540669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5885 CUMMING HWY STE 108199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR HILL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-5765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-589-9292
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2070 LEE PETERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30052-4193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-589-9292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
FOUNTAIN
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
470-589-9292

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DN012292 . This is a "DENTAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: DN011027 . This is a "GEORGIA BOARD OF DENTISTRY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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