Provider Demographics
NPI:1760921480
Name:PEACHTREE CHILDRENS DENTISTRY GAINESVILLE LLC
Entity Type:Organization
Organization Name:PEACHTREE CHILDRENS DENTISTRY GAINESVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAMEUN
Authorized Official - Middle Name:NANCY
Authorized Official - Last Name:KIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-438-1833
Mailing Address - Street 1:885 DAWSONVILLE HWY.
Mailing Address - Street 2:SUITE 1130
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:885 DAWSONVILLE HWY.
Practice Address - Street 2:SUITE 1130
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-497-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty