Provider Demographics
NPI:1124373139
Name:EXECUTIVE PARK DENTISTRY, P.C.
Entity type:Organization
Organization Name:EXECUTIVE PARK DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAMJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-664-6876
Mailing Address - Street 1:17 EXECUTIVE PARK DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 EXECUTIVE PARK DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2251
Practice Address - Country:US
Practice Address - Phone:404-633-0715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty