Provider Demographics
NPI:1205231271
Name:PERIODONTAL SPECIALISTS OF VININGS
Entity Type:Organization
Organization Name:PERIODONTAL SPECIALISTS OF VININGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BEZREH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS, ABP
Authorized Official - Phone:678-677-9288
Mailing Address - Street 1:100 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3179
Mailing Address - Country:US
Mailing Address - Phone:678-236-0500
Mailing Address - Fax:678-236-0586
Practice Address - Street 1:100 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3179
Practice Address - Country:US
Practice Address - Phone:678-236-0500
Practice Address - Fax:678-236-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty