Provider Demographics
NPI:1285973230
Name:LITHONIA PEDIATRIC DENTISTRY-STONECREST INC
Entity type:Organization
Organization Name:LITHONIA PEDIATRIC DENTISTRY-STONECREST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:TAE
Authorized Official - Last Name:SHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-482-4661
Mailing Address - Street 1:7215 STONECREST PKWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2563
Mailing Address - Country:US
Mailing Address - Phone:770-482-4661
Mailing Address - Fax:770-482-4606
Practice Address - Street 1:7215 STONECREST PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2563
Practice Address - Country:US
Practice Address - Phone:770-482-4661
Practice Address - Fax:770-482-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty