Provider Demographics
NPI:1528491644
Name:PEACHSTATE PERIO AND IMPLANTS, INC.
Entity type:Organization
Organization Name:PEACHSTATE PERIO AND IMPLANTS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAGE
Authorized Official - Middle Name:PHELPS
Authorized Official - Last Name:BARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-272-2512
Mailing Address - Street 1:1024 MARKET PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7921
Mailing Address - Country:US
Mailing Address - Phone:770-844-6771
Mailing Address - Fax:
Practice Address - Street 1:1024 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7921
Practice Address - Country:US
Practice Address - Phone:770-844-6771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010757261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental