Provider Demographics
NPI:1508038076
Name:FABULOUS DENTISTRY AND ORTHODONTIC PC
Entity Type:Organization
Organization Name:FABULOUS DENTISTRY AND ORTHODONTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOLANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-325-3970
Mailing Address - Street 1:950 INDIAN TRL RD NW
Mailing Address - Street 2:SUITE 3-G
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1721
Mailing Address - Country:US
Mailing Address - Phone:678-325-3970
Mailing Address - Fax:678-325-3971
Practice Address - Street 1:950 INDIAN TRL RD NW
Practice Address - Street 2:SUITE 3-G
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1721
Practice Address - Country:US
Practice Address - Phone:678-325-3970
Practice Address - Fax:678-325-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA502321377BMedicaid