Provider Demographics
NPI:1538826359
Name:POLISH DENTAL CENTER MARIETTA LLC
Entity type:Organization
Organization Name:POLISH DENTAL CENTER MARIETTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-714-8433
Mailing Address - Street 1:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30023-2036
Mailing Address - Country:US
Mailing Address - Phone:770-642-4711
Mailing Address - Fax:
Practice Address - Street 1:598 NANCY ST NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1375
Practice Address - Country:US
Practice Address - Phone:770-642-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003111882AMedicaid