Provider Demographics
NPI:1235875295
Name:GWINNETT DENTAL CARE LAWRENCEVILLE LLC
Entity Type:Organization
Organization Name:GWINNETT DENTAL CARE LAWRENCEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-520-7534
Mailing Address - Street 1:301 PAPER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5366
Mailing Address - Country:US
Mailing Address - Phone:678-520-7534
Mailing Address - Fax:
Practice Address - Street 1:911 DULUTH HWY STE E2
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5399
Practice Address - Country:US
Practice Address - Phone:678-520-7534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental