Provider Demographics
NPI:1467222588
Name:MOUNTAIN CITY DENTISTRY LLC
Entity Type:Organization
Organization Name:MOUNTAIN CITY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIESSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-445-4377
Mailing Address - Street 1:7925 SCENIC RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-5102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 GORDON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:770-744-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty