Provider Demographics
NPI:1295066892
Name:GRACE S. GAVRIC, DDS, LLC.
Entity type:Organization
Organization Name:GRACE S. GAVRIC, DDS, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:GAVRIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-980-0558
Mailing Address - Street 1:1100 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3064
Mailing Address - Country:US
Mailing Address - Phone:770-980-0558
Mailing Address - Fax:770-980-1092
Practice Address - Street 1:1100 CIRCLE 75 PKWY SE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3064
Practice Address - Country:US
Practice Address - Phone:770-980-0558
Practice Address - Fax:770-980-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty