Provider Demographics
NPI:1598067993
Name:GRAYSON PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:GRAYSON PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHA YAMINI
Authorized Official - Middle Name:
Authorized Official - Last Name:PONUGOTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-613-5095
Mailing Address - Street 1:12792 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-7338
Mailing Address - Country:US
Mailing Address - Phone:678-613-5095
Mailing Address - Fax:
Practice Address - Street 1:2594 LOGANVILLE HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7848
Practice Address - Country:US
Practice Address - Phone:678-682-9819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty