Provider Demographics
NPI:1700977360
Name:ATLANTA WEST PERIODONTICS AND DENTAL IMPLANTS PC
Entity Type:Organization
Organization Name:ATLANTA WEST PERIODONTICS AND DENTAL IMPLANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-739-5097
Mailing Address - Street 1:2168 SKYVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122
Mailing Address - Country:US
Mailing Address - Phone:770-739-5097
Mailing Address - Fax:770-739-0517
Practice Address - Street 1:2168 SKYVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122
Practice Address - Country:US
Practice Address - Phone:770-739-5097
Practice Address - Fax:770-739-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10752122300000X
MI2901016263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BW2164426OtherDEA
GA19NCBVFMedicare ID - Type Unspecified