Organization
ITARUT DENTAL LLC
Active
Other names
Northlake Family Dentistry
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PIYANUT ITARUT DMD (ORGANIZER)
(618) 977-6071
Entity
Organization
Contact information
Practice address
3756 LA VISTA RD, SUITE 102, TUCKER, GA 30084-5642
(404) 636-4700
Mailing address
3756 LA VISTA RD, SUITE 102, TUCKER, GA 30084-5642
(404) 636-4700
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
01/24/2019
Last updated
01/24/2019
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