Provider Demographics
NPI:1184031239
Name:PETER V. VANSTROM, DDS, PC
Entity Type:Organization
Organization Name:PETER V. VANSTROM, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:V
Authorized Official - Last Name:VANSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-325-2905
Mailing Address - Street 1:2296 HENDERSON MILL RD NE STE 108
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2739
Mailing Address - Country:US
Mailing Address - Phone:404-325-2905
Mailing Address - Fax:678-735-3148
Practice Address - Street 1:2296 HENDERSON MILL RD NE STE 108
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2739
Practice Address - Country:US
Practice Address - Phone:404-325-2905
Practice Address - Fax:678-735-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty