Provider Demographics
NPI:1104167865
Name:GWINNETT FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:GWINNETT FAMILY DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:BARRIONUEVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-921-5100
Mailing Address - Street 1:504 INDIAN TRAIL LILBURN RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3720
Mailing Address - Country:US
Mailing Address - Phone:770-921-5100
Mailing Address - Fax:
Practice Address - Street 1:504 INDIAN TRAIL LILBURN RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3720
Practice Address - Country:US
Practice Address - Phone:770-921-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty