Provider Demographics
NPI:1003124066
Name:CHAMBLEE DUNWOODY FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:CHAMBLEE DUNWOODY FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:BUCHANAN
Authorized Official - Last Name:WESTOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-455-6076
Mailing Address - Street 1:3781 CHAMBLEE DUNWOODY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-455-6076
Mailing Address - Fax:770-455-0400
Practice Address - Street 1:3781 CHAMBLEE DUNWOODY ROAD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-455-6076
Practice Address - Fax:770-455-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty