Provider Demographics
NPI:1255409157
Name:ROSWELL FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:ROSWELL FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-998-6000
Mailing Address - Street 1:380 MARKET PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSWELL G
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3943
Mailing Address - Country:US
Mailing Address - Phone:770-998-6000
Mailing Address - Fax:770-993-5200
Practice Address - Street 1:380 MARKET PL
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3943
Practice Address - Country:US
Practice Address - Phone:770-998-6000
Practice Address - Fax:770-993-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty