Provider Demographics
NPI:1770834954
Name:EDGEWOOD DENTAL CENTER
Entity Type:Organization
Organization Name:EDGEWOOD DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-758-0770
Mailing Address - Street 1:545 EDGEWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1936
Mailing Address - Country:US
Mailing Address - Phone:404-589-0900
Mailing Address - Fax:404-537-3107
Practice Address - Street 1:545 EDGEWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1936
Practice Address - Country:US
Practice Address - Phone:404-589-0900
Practice Address - Fax:404-537-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental