Provider Demographics
NPI:1093414146
Name:SUPREME DENTAL GROUP LLC
Entity Type:Organization
Organization Name:SUPREME DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:XIAODAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-744-3855
Mailing Address - Street 1:3855 JOHNS CREEK PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1293
Mailing Address - Country:US
Mailing Address - Phone:770-744-3855
Mailing Address - Fax:
Practice Address - Street 1:3855 JOHNS CREEK PKWY STE A
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1293
Practice Address - Country:US
Practice Address - Phone:770-744-3855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty