Provider Demographics
NPI:1467277228
Name:PROVIDENCE DENTAL SPA OF EAST COBB, LLC
Entity type:Organization
Organization Name:PROVIDENCE DENTAL SPA OF EAST COBB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-309-8888
Mailing Address - Street 1:670 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4627
Mailing Address - Country:US
Mailing Address - Phone:678-801-6700
Mailing Address - Fax:
Practice Address - Street 1:670 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4627
Practice Address - Country:US
Practice Address - Phone:678-801-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental