Provider Demographics
NPI:1518988658
Name:BRAELINN VILLAGE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BRAELINN VILLAGE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-486-9400
Mailing Address - Street 1:424 CROSSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2915
Mailing Address - Country:US
Mailing Address - Phone:770-486-9400
Mailing Address - Fax:770-486-8814
Practice Address - Street 1:424 CROSSTOWN RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2915
Practice Address - Country:US
Practice Address - Phone:770-486-9400
Practice Address - Fax:770-486-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty