Provider Demographics
NPI:1740723311
Name:MICHELLE GWYN DDS, PC
Entity type:Organization
Organization Name:MICHELLE GWYN DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:SANDRA
Authorized Official - Last Name:GWYN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-304-8408
Mailing Address - Street 1:5040 BILL GARDNER PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3758
Mailing Address - Country:US
Mailing Address - Phone:678-304-8408
Mailing Address - Fax:689-304-8409
Practice Address - Street 1:5040 BILL GARDNER PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3758
Practice Address - Country:US
Practice Address - Phone:678-304-8408
Practice Address - Fax:689-304-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA675686848CMedicaid