Provider Demographics
NPI:1851765663
Name:IMAGIX FAMILY DENTISTRY OF VININGS LLC
Entity Type:Organization
Organization Name:IMAGIX FAMILY DENTISTRY OF VININGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOUINARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-955-3150
Mailing Address - Street 1:2460 CUMBERLAND PKWY SE
Mailing Address - Street 2:210
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4519
Mailing Address - Country:US
Mailing Address - Phone:770-433-2414
Mailing Address - Fax:
Practice Address - Street 1:2460 CUMBERLAND PKWY SE
Practice Address - Street 2:210
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4519
Practice Address - Country:US
Practice Address - Phone:770-433-2414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty