Basic Information
| Provider Information | |||||||||
| NPI: | 1487030847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACHTREE CITY DENTAL GROUP, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEACHTREE DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 920050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753920050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 N PEACHTREE PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702689112 | ||||||||
| FaxNumber: | 7706310023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYAN | ||||||||
| AuthorizedOfficialFirstName: | JELANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7702689112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.