Provider Demographics
NPI:1720303480
Name:OPTIMA DENTAL PC
Entity Type:Organization
Organization Name:OPTIMA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ISIOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANIZOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-962-4322
Mailing Address - Street 1:4825 SUGARLOAF PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8800
Mailing Address - Country:US
Mailing Address - Phone:770-962-4322
Mailing Address - Fax:678-407-2787
Practice Address - Street 1:4825 SUGARLOAF PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8800
Practice Address - Country:US
Practice Address - Phone:770-962-4322
Practice Address - Fax:678-407-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA122300000XMedicaid