Provider Demographics
NPI:1508954116
Name:LANIER ORTHODONTICS PA
Entity Type:Organization
Organization Name:LANIER ORTHODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KYM
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-532-8104
Mailing Address - Street 1:1215 SHERWOOD PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3444
Mailing Address - Country:US
Mailing Address - Phone:770-532-4156
Mailing Address - Fax:770-536-1529
Practice Address - Street 1:1215 SHERWOOD PARK DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3444
Practice Address - Country:US
Practice Address - Phone:770-532-4156
Practice Address - Fax:770-536-1529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0110671223X0400X
GADN0118991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty