Provider Demographics
NPI:1740956572
Name:PEACH STATE DENTAL IMPLANTS AND PERIODONTICS
Entity type:Organization
Organization Name:PEACH STATE DENTAL IMPLANTS AND PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR/OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALISSA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:GIANFALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-500-8446
Mailing Address - Street 1:4300 WESTBROOK RD # F
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4987
Mailing Address - Country:US
Mailing Address - Phone:770-310-7822
Mailing Address - Fax:
Practice Address - Street 1:4300 WESTBROOK RD # F
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4987
Practice Address - Country:US
Practice Address - Phone:770-310-7822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty