Provider Demographics
NPI:1477630556
Name:EAST 53RD STREET DENTAL-1, PC
Entity Type:Organization
Organization Name:EAST 53RD STREET DENTAL-1, PC
Other - Org Name:PIPPIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-916-5036
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:770-916-5028
Mailing Address - Fax:678-247-7858
Practice Address - Street 1:3658 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1239
Practice Address - Country:US
Practice Address - Phone:317-781-5667
Practice Address - Fax:317-781-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty