Provider Demographics
NPI:1760615629
Name:ATLANTA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ATLANTA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JEON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-850-8442
Mailing Address - Street 1:2394 COBB PKWY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3061
Mailing Address - Country:US
Mailing Address - Phone:770-850-8442
Mailing Address - Fax:770-850-8052
Practice Address - Street 1:2394 COBB PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3061
Practice Address - Country:US
Practice Address - Phone:770-850-8442
Practice Address - Fax:770-850-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO131961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA733999822AMedicaid