Provider Demographics
NPI:1609918622
Name:AVENUE DENTAL LLC
Entity Type:Organization
Organization Name:AVENUE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUHANNAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDEIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-888-4444
Mailing Address - Street 1:983 PEACHTREE PARKWAY SUITE C
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041
Mailing Address - Country:US
Mailing Address - Phone:770-888-4444
Mailing Address - Fax:770-888-4448
Practice Address - Street 1:983 PEACHTREE PARKWAY SUITE C
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-888-4444
Practice Address - Fax:770-888-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013053261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental