Provider Demographics
NPI:1437573748
Name:DENTISTRY AT HICKORY FLAT PC
Entity Type:Organization
Organization Name:DENTISTRY AT HICKORY FLAT PC
Other - Org Name:DENTISTRY AT HICKORY FLAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-213-8166
Mailing Address - Street 1:6199 HICKORY FLAT HWY STE 130
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7255
Mailing Address - Country:US
Mailing Address - Phone:770-213-8166
Mailing Address - Fax:770-213-8157
Practice Address - Street 1:6199 HICKORY FLAT HWY STE 130
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7255
Practice Address - Country:US
Practice Address - Phone:770-213-8166
Practice Address - Fax:770-213-8157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
GADN013420261QD0000X
GADN013473261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental