Provider Demographics
NPI:1063095842
Name:EVOLUTION DENTAL SURGERY AND AESTHETIC CENTERS
Entity type:Organization
Organization Name:EVOLUTION DENTAL SURGERY AND AESTHETIC CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-951-3147
Mailing Address - Street 1:3775 VENTURE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5102
Mailing Address - Country:US
Mailing Address - Phone:470-387-0385
Mailing Address - Fax:678-550-4999
Practice Address - Street 1:3775 VENTURE DR STE 101
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5102
Practice Address - Country:US
Practice Address - Phone:470-387-0385
Practice Address - Fax:678-550-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty