Provider Demographics
NPI:1932461860
Name:SACRED DENTAL
Entity Type:Organization
Organization Name:SACRED DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AGATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWIZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-9202
Mailing Address - Street 1:1360 DOGWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5075
Mailing Address - Country:US
Mailing Address - Phone:770-474-9202
Mailing Address - Fax:770-474-9842
Practice Address - Street 1:1360 DOGWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-474-9202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty