Provider Demographics
NPI:1023283181
Name:NORCROSS DENTAL CENTER
Entity type:Organization
Organization Name:NORCROSS DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THIEN
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-411-7900
Mailing Address - Street 1:5430 JIMMY CARTER BLVD STE 125
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5430 JIMMY CARTER BLVD STE 125
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1526
Practice Address - Country:US
Practice Address - Phone:770-441-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA232256189BMedicaid
GA232256189CMedicaid