Provider Demographics
NPI:1487173217
Name:BREMEN DENTAL DEPOT LLC
Entity type:Organization
Organization Name:BREMEN DENTAL DEPOT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-822-4714
Mailing Address - Street 1:302 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-2124
Mailing Address - Country:US
Mailing Address - Phone:770-537-4439
Mailing Address - Fax:770-537-3708
Practice Address - Street 1:302 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2124
Practice Address - Country:US
Practice Address - Phone:770-537-4439
Practice Address - Fax:770-537-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental