Basic Information
| Provider Information | |||||||||
| NPI: | 1972687903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTON DENTAL-1, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KOOL SMILES SC, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709165036 | ||||||||
| FaxNumber: | 6782854760 | ||||||||
| Practice Location | |||||||||
| Address1: | 3112 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296212763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
| FaxNumber: | 6789045669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TRAN | ||||||||
| AuthorizedOfficialFirstName: | TU | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7709169000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.