Provider Demographics
NPI:1508085671
Name:OLD MILTON DENTAL
Entity Type:Organization
Organization Name:OLD MILTON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-624-0370
Mailing Address - Street 1:4165 OLD MILTON PKWY
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4468
Mailing Address - Country:US
Mailing Address - Phone:678-624-0370
Mailing Address - Fax:678-624-0319
Practice Address - Street 1:4165 OLD MILTON PKWY
Practice Address - Street 2:SUITE 190
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4468
Practice Address - Country:US
Practice Address - Phone:678-624-0370
Practice Address - Fax:678-624-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012287122300000X
GA012301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty