Provider Demographics
NPI:1689961229
Name:ATLANTA ENDODONTIC GROUP PC
Entity Type:Organization
Organization Name:ATLANTA ENDODONTIC GROUP PC
Other - Org Name:MCDONOUGH ENDODONTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENDODONTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-954-0072
Mailing Address - Street 1:1705 HWY 20 W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253
Mailing Address - Country:US
Mailing Address - Phone:770-954-0072
Mailing Address - Fax:770-954-0074
Practice Address - Street 1:1705 HWY 20 W
Practice Address - Street 2:SUITE 200
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253
Practice Address - Country:US
Practice Address - Phone:770-954-8672
Practice Address - Fax:770-954-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-04
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0139451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty