Provider Demographics
NPI:1154743136
Name:BELLA COSMETIC AND FAMILY DENTISTRY
Entity type:Organization
Organization Name:BELLA COSMETIC AND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:S
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-921-9000
Mailing Address - Street 1:4574 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3647
Mailing Address - Country:US
Mailing Address - Phone:770-921-9000
Mailing Address - Fax:
Practice Address - Street 1:4574 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 120
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3647
Practice Address - Country:US
Practice Address - Phone:770-921-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO13198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty