Provider Demographics
NPI:1972837318
Name:FAMILY DENTISTRY OF MARIETTA, LLC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF MARIETTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-977-9090
Mailing Address - Street 1:2125 POST OAK TRITT RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1609
Mailing Address - Country:US
Mailing Address - Phone:770-977-9090
Mailing Address - Fax:
Practice Address - Street 1:2125 POST OAK TRITT RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-1609
Practice Address - Country:US
Practice Address - Phone:770-977-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty