Provider Demographics
NPI:1518355577
Name:ORTHOGENESIS, LLC
Entity Type:Organization
Organization Name:ORTHOGENESIS, LLC
Other - Org Name:BLOOM ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-680-2335
Mailing Address - Street 1:3005 ROYAL BLVD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1409
Mailing Address - Country:US
Mailing Address - Phone:770-680-2335
Mailing Address - Fax:678-550-3046
Practice Address - Street 1:3005 ROYAL BLVD S
Practice Address - Street 2:SUITE 200
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1409
Practice Address - Country:US
Practice Address - Phone:770-680-2335
Practice Address - Fax:678-550-3046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty