Provider Demographics
NPI:1285770701
Name:LILBURN DENTAL CENTER
Entity type:Organization
Organization Name:LILBURN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:EWOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-638-8090
Mailing Address - Street 1:4145 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:STE 5
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2807
Mailing Address - Country:US
Mailing Address - Phone:770-638-8090
Mailing Address - Fax:770-638-8144
Practice Address - Street 1:4145 LAWRENCEVILLE HWY NW
Practice Address - Street 2:STE 5
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2807
Practice Address - Country:US
Practice Address - Phone:770-638-8090
Practice Address - Fax:770-638-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty