Provider Demographics
NPI:1770981763
Name:PEACHTREE DUNWOODY ORAL AND FACIAL SURGERY
Entity type:Organization
Organization Name:PEACHTREE DUNWOODY ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-220-7505
Mailing Address - Street 1:5505 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 660
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1705
Mailing Address - Country:US
Mailing Address - Phone:404-220-7505
Mailing Address - Fax:404-220-7506
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 660
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1705
Practice Address - Country:US
Practice Address - Phone:404-220-7505
Practice Address - Fax:404-220-7506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0103451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty