Provider Demographics
NPI:1336250406
Name:NORTHLAKE DENTAL PARTNERS
Entity Type:Organization
Organization Name:NORTHLAKE DENTAL PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-938-3277
Mailing Address - Street 1:2300 HENDERSON MILL RD NE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2745
Mailing Address - Country:US
Mailing Address - Phone:770-938-3277
Mailing Address - Fax:770-934-1240
Practice Address - Street 1:2300 HENDERSON MILL RD NE
Practice Address - Street 2:SUITE 401
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2745
Practice Address - Country:US
Practice Address - Phone:770-938-3277
Practice Address - Fax:770-934-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty