Provider Demographics
NPI:1679029219
Name:SQUARE ONE DENTAL LLC
Entity Type:Organization
Organization Name:SQUARE ONE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SENGSOURIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANANTHASANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-888-8295
Mailing Address - Street 1:5870 CHARLOTTE LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0316
Mailing Address - Country:US
Mailing Address - Phone:770-888-8295
Mailing Address - Fax:
Practice Address - Street 1:3510 ROWE LANE
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-888-8295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012307261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental