Provider Demographics
NPI:1679877005
Name:GRANT PARK DENTAL GROUP PC
Entity Type:Organization
Organization Name:GRANT PARK DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHISH
Authorized Official - Middle Name:PRAVIN
Authorized Official - Last Name:VAKHARIA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:412-716-7907
Mailing Address - Street 1:465 BOULEVARD SE STE 207A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3483
Mailing Address - Country:US
Mailing Address - Phone:404-624-1230
Mailing Address - Fax:404-624-1210
Practice Address - Street 1:465 BOULEVARD SE STE 207A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-3483
Practice Address - Country:US
Practice Address - Phone:404-624-1230
Practice Address - Fax:404-624-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132181223G0001X
GADN0124661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty