Provider Demographics
NPI:1811045818
Name:PERIODONTICS & DENTAL IMPLANTS, LLC
Entity Type:Organization
Organization Name:PERIODONTICS & DENTAL IMPLANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-254-0401
Mailing Address - Street 1:163 JEFFERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5823
Mailing Address - Country:US
Mailing Address - Phone:770-254-0401
Mailing Address - Fax:770-254-8483
Practice Address - Street 1:163 JEFFERSON PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5823
Practice Address - Country:US
Practice Address - Phone:770-254-0401
Practice Address - Fax:770-254-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0118401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty