Basic Information
| Provider Information | |||||||||
| NPI: | 1770689119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMAGIX 3 DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 TOWN CENTER AVE | ||||||||
| Address2: | 301 | ||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788350793 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 TOWN CENTER AVE | ||||||||
| Address2: | 301 | ||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788350793 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WITKIN | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6788350793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 009491 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.