Provider Demographics
NPI:1073894911
Name:REGION DENTAL
Entity Type:Organization
Organization Name:REGION DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TOUSSIANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-736-2984
Mailing Address - Street 1:2488 SCENIC HWY S
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5710
Mailing Address - Country:US
Mailing Address - Phone:770-736-2984
Mailing Address - Fax:770-736-2987
Practice Address - Street 1:2488 SCENIC HWY S
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5710
Practice Address - Country:US
Practice Address - Phone:770-736-2984
Practice Address - Fax:770-736-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDN014167305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization