Provider Demographics
NPI:1710216783
Name:ROYAL LAKES FAMILY AND COSMETIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:ROYAL LAKES FAMILY AND COSMETIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-531-3232
Mailing Address - Street 1:4005 WINDER HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-6564
Mailing Address - Country:US
Mailing Address - Phone:770-531-3232
Mailing Address - Fax:770-531-3238
Practice Address - Street 1:4005 WINDER HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-6564
Practice Address - Country:US
Practice Address - Phone:770-531-3232
Practice Address - Fax:770-531-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1699711416OtherINDIVIDUAL NPI NUMBER