Provider Demographics
NPI:1043530686
Name:SUWANEE STATION DENTISTRY, LLC
Entity Type:Organization
Organization Name:SUWANEE STATION DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-831-5568
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 4103
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4539
Mailing Address - Country:US
Mailing Address - Phone:770-831-5568
Mailing Address - Fax:770-831-5527
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 4103
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4539
Practice Address - Country:US
Practice Address - Phone:770-831-5568
Practice Address - Fax:770-831-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-06
Last Update Date:2010-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0125481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty