Provider Demographics
NPI:1073056933
Name:FAYETTEVILLE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FAYETTEVILLE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NATH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-651-1000
Mailing Address - Street 1:320 N JEFF DAVIS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1669
Mailing Address - Country:US
Mailing Address - Phone:770-651-1000
Mailing Address - Fax:
Practice Address - Street 1:320 N JEFF DAVIS DR
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1669
Practice Address - Country:US
Practice Address - Phone:770-651-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty