Provider Demographics
NPI:1407208291
Name:PERRY STREET DENTAL, P.C.
Entity Type:Organization
Organization Name:PERRY STREET DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:MOYNAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-251-3465
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:770-916-5031
Mailing Address - Fax:678-247-7966
Practice Address - Street 1:53 PERRY ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1935
Practice Address - Country:US
Practice Address - Phone:770-251-3465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty