Provider Demographics
NPI:1619638814
Name:CENTER FOR COSMETIC AND SEDATION DENTISTRY JOHNS CREEK, LLC
Entity Type:Organization
Organization Name:CENTER FOR COSMETIC AND SEDATION DENTISTRY JOHNS CREEK, LLC
Other - Org Name:CENTER FOR COSMETIC AND SEDATION DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-1957
Mailing Address - Street 1:3440 OLD ALABAMA RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3440 OLD ALABAMA RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-5525
Practice Address - Country:US
Practice Address - Phone:770-475-0603
Practice Address - Fax:770-753-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental