Provider Demographics
NPI:1528331923
Name:ATLANTA DENTAL TEAM STONE MOUNTAIN PC
Entity type:Organization
Organization Name:ATLANTA DENTAL TEAM STONE MOUNTAIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-469-1331
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2978
Mailing Address - Country:US
Mailing Address - Phone:770-469-1331
Mailing Address - Fax:
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2978
Practice Address - Country:US
Practice Address - Phone:770-469-1331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN09316122300000X
GA12130GA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000386625AMedicaid