Provider Demographics
NPI:1063137925
Name:GLEE DENTAL
Entity type:Organization
Organization Name:GLEE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLUBUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OSUNFISAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-961-3370
Mailing Address - Street 1:3485 ACWORTH DUE WEST RD NW STE 160
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-3870
Mailing Address - Country:US
Mailing Address - Phone:678-961-3370
Mailing Address - Fax:
Practice Address - Street 1:3485 ACWORTH DUE WEST RD NW STE 160
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-3870
Practice Address - Country:US
Practice Address - Phone:678-961-3370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental