Provider Demographics
NPI:1427207323
Name:NORTHBRIDGE DENTAL, LLP
Entity Type:Organization
Organization Name:NORTHBRIDGE DENTAL, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-319-0210
Mailing Address - Street 1:11060 ALPHARETTA HWY
Mailing Address - Street 2:SUITE #162
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1472
Mailing Address - Country:US
Mailing Address - Phone:678-352-9890
Mailing Address - Fax:678-352-9892
Practice Address - Street 1:11060 ALPHARETTA HWY
Practice Address - Street 2:SUITE #162
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1472
Practice Address - Country:US
Practice Address - Phone:678-352-9890
Practice Address - Fax:678-352-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011752302R00000X
GA011781302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA519326539BMedicaid
GA734279204CMedicaid