Provider Demographics
NPI:1306019906
Name:MIDTOWN DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:MIDTOWN DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LELA
Authorized Official - Middle Name:II
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-753-3339
Mailing Address - Street 1:1014 RALPH DAVID ABERNATHY BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1812
Mailing Address - Country:US
Mailing Address - Phone:404-753-3339
Mailing Address - Fax:404-753-1858
Practice Address - Street 1:1014 RALPH DAVID ABERNATHY BLVD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1812
Practice Address - Country:US
Practice Address - Phone:404-753-3339
Practice Address - Fax:404-753-1858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00263645DMedicaid