Provider Demographics
NPI:1508540196
Name:BROOKHAVEN VILLAGE DENTISTRY
Entity Type:Organization
Organization Name:BROOKHAVEN VILLAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-683-2444
Mailing Address - Street 1:4513 WIEUCA RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2814 BUFORD HWY NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2103
Practice Address - Country:US
Practice Address - Phone:404-683-2444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental