Provider Demographics
NPI:1154069391
Name:BENTWATER COSMETIC AND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BENTWATER COSMETIC AND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:THRELKELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-499-3514
Mailing Address - Street 1:351 THORNTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1589
Mailing Address - Country:US
Mailing Address - Phone:770-944-9755
Mailing Address - Fax:770-944-1261
Practice Address - Street 1:351 THORNTON RD STE 101
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1589
Practice Address - Country:US
Practice Address - Phone:770-944-9755
Practice Address - Fax:770-944-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN011428OtherDENTAL LICENSE NUMBER