Provider Demographics
NPI:1477208437
Name:PEACHTREE MODERN DENTISTRY, PC
Entity type:Organization
Organization Name:PEACHTREE MODERN DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-272-3964
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:
Practice Address - Street 1:125 FISCHER CROSSING DRIVE
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277
Practice Address - Country:US
Practice Address - Phone:678-272-3964
Practice Address - Fax:678-325-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty