Provider Demographics
NPI:1558664227
Name:CORNERSTONE DENTSITRY; PC
Entity Type:Organization
Organization Name:CORNERSTONE DENTSITRY; PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-932-6510
Mailing Address - Street 1:2463 HAMILTON MILL PKWY
Mailing Address - Street 2:240
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4648
Mailing Address - Country:US
Mailing Address - Phone:770-932-6510
Mailing Address - Fax:
Practice Address - Street 1:2463 HAMILTON MILL PKWY
Practice Address - Street 2:240
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4648
Practice Address - Country:US
Practice Address - Phone:770-932-6510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA847469223CMedicaid