Provider Demographics
NPI:1326897802
Name:BESPOKE DENTAL LLC
Entity type:Organization
Organization Name:BESPOKE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RASK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-552-4904
Mailing Address - Street 1:2201 NEWNAN CROSSING BLVD E STE 202
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2551
Mailing Address - Country:US
Mailing Address - Phone:678-552-4904
Mailing Address - Fax:678-552-4905
Practice Address - Street 1:2201 NEWNAN CROSSING BLVD E STE 202
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2551
Practice Address - Country:US
Practice Address - Phone:678-552-4904
Practice Address - Fax:678-552-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental