Provider Demographics
NPI:1336896430
Name:WESTSIDE DENTAL, LLC
Entity type:Organization
Organization Name:WESTSIDE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:470-548-2962
Mailing Address - Street 1:698 LEXINGTON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-3536
Mailing Address - Country:US
Mailing Address - Phone:859-620-7587
Mailing Address - Fax:
Practice Address - Street 1:929 LEE ST SW
Practice Address - Street 2:SUITE A240
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310
Practice Address - Country:US
Practice Address - Phone:859-620-7587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental