Provider Demographics
NPI:1033344650
Name:LOGANVILLE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LOGANVILLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PONNIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:POISAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-466-3114
Mailing Address - Street 1:3973 ATLANTA HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3752
Mailing Address - Country:US
Mailing Address - Phone:770-466-3114
Mailing Address - Fax:770-466-3777
Practice Address - Street 1:3973 ATLANTA HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3752
Practice Address - Country:US
Practice Address - Phone:770-466-3114
Practice Address - Fax:770-466-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty