Provider Demographics
NPI:1619013802
Name:WINDWARD PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:WINDWARD PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YANGSUN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-344-0170
Mailing Address - Street 1:11730 JONES BRIDGE RD
Mailing Address - Street 2:STE B, C, & D
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5077
Mailing Address - Country:US
Mailing Address - Phone:770-344-0170
Mailing Address - Fax:770-344-0169
Practice Address - Street 1:11730 JONES BRIDGE RD
Practice Address - Street 2:STE B, C, & D
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-5077
Practice Address - Country:US
Practice Address - Phone:770-344-0170
Practice Address - Fax:770-344-0169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126781223P0221X
GADN0126791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty