Provider Demographics
NPI:1174794002
Name:GEORGIA ENDODONTIC SPECIALISTS
Entity type:Organization
Organization Name:GEORGIA ENDODONTIC SPECIALISTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LES
Authorized Official - Middle Name:HALE
Authorized Official - Last Name:KRAVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-232-5112
Mailing Address - Street 1:9590 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:770-232-5112
Mailing Address - Fax:770-232-5115
Practice Address - Street 1:9590 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE G
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:770-232-5112
Practice Address - Fax:770-232-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106361223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty