Provider Demographics
NPI:1225399082
Name:PARK VILLAGE DENTAL GROUP
Entity Type:Organization
Organization Name:PARK VILLAGE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-814-7791
Mailing Address - Street 1:2550 PLEASANT HILL RD
Mailing Address - Street 2:SUITE #115
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4122
Mailing Address - Country:US
Mailing Address - Phone:770-814-7791
Mailing Address - Fax:770-814-7792
Practice Address - Street 1:2550 PLEASANT HILL RD
Practice Address - Street 2:SUITE #115
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4122
Practice Address - Country:US
Practice Address - Phone:770-814-7791
Practice Address - Fax:770-814-7792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0124971223G0001X
GA0135511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty