Provider Demographics
NPI:1841512324
Name:LITHONIA RESTORATIVE AND COSMETIC DENTAL CENTER
Entity type:Organization
Organization Name:LITHONIA RESTORATIVE AND COSMETIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-593-8249
Mailing Address - Street 1:6118 COVINGTON HWY STE E
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8379
Mailing Address - Country:US
Mailing Address - Phone:770-593-8249
Mailing Address - Fax:770-323-6887
Practice Address - Street 1:6118 COVINGTON HWY STE E
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8379
Practice Address - Country:US
Practice Address - Phone:770-593-8249
Practice Address - Fax:770-323-6887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty