Provider Demographics
NPI:1518165141
Name:GREAT EXPRESSIONS DENTAL CENTERS OF GEORGIA, PC
Entity Type:Organization
Organization Name:GREAT EXPRESSIONS DENTAL CENTERS OF GEORGIA, PC
Other - Org Name:NANSTON DENTAL GROUP, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-203-1100
Mailing Address - Street 1:300 E. LONG LAKE RD
Mailing Address - Street 2:STE 311
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304
Mailing Address - Country:US
Mailing Address - Phone:248-203-1100
Mailing Address - Fax:248-723-0052
Practice Address - Street 1:300 E. LONG LAKE RD
Practice Address - Street 2:STE 311
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:248-203-1100
Practice Address - Fax:248-723-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN006556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty