Provider Demographics
NPI:1922380633
Name:LIFETIME DENTAL GROUP LLC
Entity Type:Organization
Organization Name:LIFETIME DENTAL GROUP LLC
Other - Org Name:GWINNETT PLACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALACIOS-BARRIONUEVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-842-4900
Mailing Address - Street 1:3920 SHILOH RIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3796 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5699
Practice Address - Country:US
Practice Address - Phone:770-476-4140
Practice Address - Fax:770-497-9435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0143331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty