Provider Demographics
NPI:1568133627
Name:DG DENTAL LLC
Entity Type:Organization
Organization Name:DG DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRODIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-851-8383
Mailing Address - Street 1:1101 JUNIPER ST NE APT 707
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-7659
Mailing Address - Country:US
Mailing Address - Phone:770-851-8383
Mailing Address - Fax:
Practice Address - Street 1:3280 HOWELL MILL RD NW STE 327
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4109
Practice Address - Country:US
Practice Address - Phone:470-451-0981
Practice Address - Fax:470-451-0982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty