Provider Demographics
NPI:1003366147
Name:EAST COBB NIA LLC
Entity Type:Organization
Organization Name:EAST COBB NIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-479-9999
Mailing Address - Street 1:1111 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068
Mailing Address - Country:US
Mailing Address - Phone:770-479-9999
Mailing Address - Fax:
Practice Address - Street 1:1111 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2181
Practice Address - Country:US
Practice Address - Phone:770-479-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty