Provider Demographics
NPI:1801292750
Name:IMPLANT AND AESTHETIC SPECIALISTS OF ATLANTA
Entity type:Organization
Organization Name:IMPLANT AND AESTHETIC SPECIALISTS OF ATLANTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-321-4588
Mailing Address - Street 1:1991 N WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3500
Mailing Address - Country:US
Mailing Address - Phone:404-321-4588
Mailing Address - Fax:404-321-1892
Practice Address - Street 1:1991 N WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3500
Practice Address - Country:US
Practice Address - Phone:404-321-4588
Practice Address - Fax:404-321-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013111122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty