Provider Demographics
NPI:1396864237
Name:FAMILY DENTAL CENTERS OF MARIETTA, P.C.
Entity Type:Organization
Organization Name:FAMILY DENTAL CENTERS OF MARIETTA, P.C.
Other - Org Name:FAMILY DENTAL SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HETESH
Authorized Official - Middle Name:MADEV
Authorized Official - Last Name:RANCHOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-794-0808
Mailing Address - Street 1:683 PIEDMONT RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4811
Mailing Address - Country:US
Mailing Address - Phone:770-794-0808
Mailing Address - Fax:
Practice Address - Street 1:683 PIEDMONT RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4811
Practice Address - Country:US
Practice Address - Phone:770-794-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0114011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100696Medicaid
GA000683229BMedicaid
GA107742Medicaid