Provider Demographics
NPI:1336693506
Name:LOGANVILLE DENTIST OFFICE, PC
Entity Type:Organization
Organization Name:LOGANVILLE DENTIST OFFICE, PC
Other - Org Name:LOGANVILLE DENTIST OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-720-6097
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:4799 ATLANTA HWY
Practice Address - Street 2:SUITE 520
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7307
Practice Address - Country:US
Practice Address - Phone:404-720-6097
Practice Address - Fax:404-609-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty