Provider Demographics
NPI:1538506720
Name:PEDIATRIC DENTISTRY OF JOHNS CREEK, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF JOHNS CREEK, LLC
Other - Org Name:PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWERN/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-822-9818
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:501
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4433
Mailing Address - Country:US
Mailing Address - Phone:678-822-9818
Mailing Address - Fax:
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:501
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-4433
Practice Address - Country:US
Practice Address - Phone:678-822-9818
Practice Address - Fax:678-822-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty