Provider Demographics
NPI:1548810997
Name:STONE MOUNTAIN DENTAL 2, PC
Entity type:Organization
Organization Name:STONE MOUNTAIN DENTAL 2, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-452-1164
Mailing Address - Street 1:3100 FIVE FORKS TRICKUM RD SW STE 402
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1887
Mailing Address - Country:US
Mailing Address - Phone:770-837-9832
Mailing Address - Fax:404-445-8499
Practice Address - Street 1:3100 FIVE FORKS TRICKUM RD SW STE 402
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1887
Practice Address - Country:US
Practice Address - Phone:770-837-9832
Practice Address - Fax:404-445-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty