Provider Demographics
NPI:1477968410
Name:ROSWELL DENTAL STUDIO PC
Entity Type:Organization
Organization Name:ROSWELL DENTAL STUDIO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVAREZ-KIELY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-380-1404
Mailing Address - Street 1:825 NETTLEBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-0955
Mailing Address - Country:US
Mailing Address - Phone:770-380-1404
Mailing Address - Fax:
Practice Address - Street 1:355 S ATLANTA ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4934
Practice Address - Country:US
Practice Address - Phone:770-380-1404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADL0115331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty