Provider Demographics
NPI:1568636405
Name:ROSWELL PEDIATRIC DENTISTRY PC
Entity type:Organization
Organization Name:ROSWELL PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NATH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-763-2600
Mailing Address - Street 1:10930 CRABAPPLE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-5825
Mailing Address - Country:US
Mailing Address - Phone:678-763-2600
Mailing Address - Fax:678-893-0459
Practice Address - Street 1:10930 CRABAPPLE RD STE 106
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5825
Practice Address - Country:US
Practice Address - Phone:678-763-2600
Practice Address - Fax:678-893-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA761564386Medicaid