Provider Demographics
NPI:1275810129
Name:PRINCETON DENTAL GROUP-LOGANVILLE
Entity Type:Organization
Organization Name:PRINCETON DENTAL GROUP-LOGANVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-324-2012
Mailing Address - Street 1:1515 WATER SHINE WAY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:404-324-2012
Mailing Address - Fax:678-344-4642
Practice Address - Street 1:4353 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3214
Practice Address - Country:US
Practice Address - Phone:770-554-0848
Practice Address - Fax:770-554-4569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2014-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0114811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty