Provider Demographics
NPI:1346066974
Name:ATLANTA DENTAL SPA
Entity type:Organization
Organization Name:ATLANTA DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-491-3861
Mailing Address - Street 1:2556 APPLE VALLEY RD NE STE 250
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5432
Mailing Address - Country:US
Mailing Address - Phone:770-998-3838
Mailing Address - Fax:678-550-9639
Practice Address - Street 1:2556 APPLE VALLEY RD NE STE 250
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-5432
Practice Address - Country:US
Practice Address - Phone:770-998-3838
Practice Address - Fax:678-550-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty