Provider Demographics
NPI:1669871968
Name:TREMONT ROAD DENTAL, PC
Entity type:Organization
Organization Name:TREMONT ROAD DENTAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-5036
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5002 AIRPORT RD NW
Practice Address - Street 2:UNIT 130
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1607
Practice Address - Country:US
Practice Address - Phone:770-916-5031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty