Provider Demographics
NPI:1932833217
Name:MERCHANTS WALK DENTAL PC
Entity Type:Organization
Organization Name:MERCHANTS WALK DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-754-4673
Mailing Address - Street 1:3760 OLD COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5964
Mailing Address - Country:US
Mailing Address - Phone:678-754-4673
Mailing Address - Fax:
Practice Address - Street 1:1344 E COBB DR STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2726
Practice Address - Country:US
Practice Address - Phone:770-961-5055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336163955OtherNPI