Provider Demographics
NPI:1326855396
Name:EASTSIDE DENTAL GROUP
Entity type:Organization
Organization Name:EASTSIDE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEJUANQUARIES
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-559-6202
Mailing Address - Street 1:2055 BEAVER RUIN RD STE E
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-3786
Mailing Address - Country:US
Mailing Address - Phone:770-559-6202
Mailing Address - Fax:
Practice Address - Street 1:2055 BEAVER RUIN RD STE E
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-3786
Practice Address - Country:US
Practice Address - Phone:770-559-6202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental