Provider Demographics
NPI:1609230143
Name:DULUTH PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:DULUTH PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NATH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-648-2470
Mailing Address - Street 1:3796 SATELLITE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5699
Mailing Address - Country:US
Mailing Address - Phone:678-763-2600
Mailing Address - Fax:
Practice Address - Street 1:3796 SATELLITE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5699
Practice Address - Country:US
Practice Address - Phone:678-763-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty