Provider Demographics
NPI:1780456301
Name:TOWN DENTISTRY BROOKHAVEN, LLC
Entity type:Organization
Organization Name:TOWN DENTISTRY BROOKHAVEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FRODGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-476-0814
Mailing Address - Street 1:804 TOWN BLVD NE STE 2010
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3147
Mailing Address - Country:US
Mailing Address - Phone:404-631-6277
Mailing Address - Fax:
Practice Address - Street 1:804 TOWN BLVD NE STE 2010
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3147
Practice Address - Country:US
Practice Address - Phone:404-631-6277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty