Provider Demographics
NPI:1679942049
Name:SPECTRUM DENTAL CARE
Entity Type:Organization
Organization Name:SPECTRUM DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IFEANYI
Authorized Official - Middle Name:EZUNU
Authorized Official - Last Name:N
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-263-8408
Mailing Address - Street 1:6270 SMITHPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2754
Mailing Address - Country:US
Mailing Address - Phone:770-263-8408
Mailing Address - Fax:770-263-8744
Practice Address - Street 1:6270 SMITHPOINTE DR
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2754
Practice Address - Country:US
Practice Address - Phone:770-263-8408
Practice Address - Fax:770-263-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000972694AMedicaid