Provider Demographics
NPI:1689002610
Name:PATRIOTS PARK DENTAL, LLC
Entity Type:Organization
Organization Name:PATRIOTS PARK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-664-0744
Mailing Address - Street 1:701 DEVIKA DR STE 10
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5136
Mailing Address - Country:US
Mailing Address - Phone:706-664-0744
Mailing Address - Fax:
Practice Address - Street 1:701 DEVIKA DRIVE, STE 10
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813
Practice Address - Country:US
Practice Address - Phone:706-664-0744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty