Provider Demographics
NPI:1407027477
Name:IMAGIX DENTAL MANAGEMENT GROUP IV LLC
Entity Type:Organization
Organization Name:IMAGIX DENTAL MANAGEMENT GROUP IV LLC
Other - Org Name:IMAGIX IV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-777-7427
Mailing Address - Street 1:1345 HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3816
Mailing Address - Country:US
Mailing Address - Phone:770-777-7427
Mailing Address - Fax:
Practice Address - Street 1:1345 HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3816
Practice Address - Country:US
Practice Address - Phone:770-777-7427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO094911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty