Provider Demographics
NPI:1255653366
Name:DECATUR DENTAL CENTER
Entity Type:Organization
Organization Name:DECATUR DENTAL CENTER
Other - Org Name:DECATUR DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABBAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-567-8485
Mailing Address - Street 1:3521 MEMORIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2731
Mailing Address - Country:US
Mailing Address - Phone:404-567-8485
Mailing Address - Fax:404-567-8487
Practice Address - Street 1:3521 MEMORIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2731
Practice Address - Country:US
Practice Address - Phone:404-567-8485
Practice Address - Fax:404-567-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty