Provider Demographics
NPI:1578731907
Name:MAMUT, LANA LVOVNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:LVOVNA
Last Name:MAMUT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LANA
Other - Middle Name:LVOVNA
Other - Last Name:MAMUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3130 MATHIS AIRPORT PKWY
Mailing Address - Street 2:STE 309
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-9131
Mailing Address - Country:US
Mailing Address - Phone:404-579-0519
Mailing Address - Fax:
Practice Address - Street 1:3130 MATHIS AIRPORT PKWY
Practice Address - Street 2:STE 309
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-9131
Practice Address - Country:US
Practice Address - Phone:404-579-0519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice