Provider Demographics
NPI:1174051908
Name:PEACH BLOSSOM DENTAL, LLC
Entity type:Organization
Organization Name:PEACH BLOSSOM DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-934-5144
Mailing Address - Street 1:2256 NORTHLAKE PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4004
Mailing Address - Country:US
Mailing Address - Phone:770-934-5144
Mailing Address - Fax:678-273-3634
Practice Address - Street 1:2256 NORTHLAKE PKWY STE 150
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4004
Practice Address - Country:US
Practice Address - Phone:770-934-5144
Practice Address - Fax:678-273-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental