Provider Demographics
NPI:1952540411
Name:METRO DENTAL @ NORTHLAKE
Entity Type:Organization
Organization Name:METRO DENTAL @ NORTHLAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTYE
Authorized Official - Middle Name:G
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-761-8455
Mailing Address - Street 1:2258 NORTHLAKE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4019
Mailing Address - Country:US
Mailing Address - Phone:678-937-9601
Mailing Address - Fax:678-937-9602
Practice Address - Street 1:2258 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4019
Practice Address - Country:US
Practice Address - Phone:678-937-9601
Practice Address - Fax:678-937-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA131961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1154490639Medicaid