Provider Demographics
NPI:1003291329
Name:DAMIAN SOMMERVILLE, DDS
Entity Type:Organization
Organization Name:DAMIAN SOMMERVILLE, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-423-0324
Mailing Address - Street 1:1951 CANTON RD
Mailing Address - Street 2:STE 310
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6327
Mailing Address - Country:US
Mailing Address - Phone:770-423-0324
Mailing Address - Fax:
Practice Address - Street 1:1951 CANTON RD
Practice Address - Street 2:STE 310
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6327
Practice Address - Country:US
Practice Address - Phone:770-423-0324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0148991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160400AMedicaid