Ga Southern Dental Ppo

NPI #1417783291 in Suwanee, Georgia

Provider Information

NPI Number: 1417783291
Entity Type: Organization
Organization Name: Ga Southern Dental Ppo
Subpart: Yes (part of a larger organization)
Parent Organization: GA SOUTHERN DENTAL PPO
Primary Specialty: Dentist
Enumeration Date: Sep 10, 2024
Last Updated: Sep 10, 2024

Practice Location

Address: 1000 PEACHTREE INDUSTRIAL BLVD STE 10
City: Suwanee
State: Georgia
ZIP Code: 30024-1977
Phone: (770) 614-4666

Authorized Official

Name: ERIKA MELISSA MENJIVAR
Title: SR. CREDENTIALING SPECIALIST
Phone: (469) 596-6137

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist	122300000X	Primary

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