Provider Demographics
NPI:1962763011
Name:HAMILTON COSMETIC AND IMPLANT DENTISTRY, PC
Entity type:Organization
Organization Name:HAMILTON COSMETIC AND IMPLANT DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOLIVAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPERON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-903-8684
Mailing Address - Street 1:2725 HAMILTON MILL RD
Mailing Address - Street 2:SUIT 700
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4187
Mailing Address - Country:US
Mailing Address - Phone:770-932-8577
Mailing Address - Fax:
Practice Address - Street 1:2725 HAMILTON MILL RD
Practice Address - Street 2:SUIT 700
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4187
Practice Address - Country:US
Practice Address - Phone:770-932-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013214305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization