Individual
VY DO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
5460 LILBURN STONE MOUNTAIN RD, STONE MOUNTAIN, GA 30087-2843
(770) 923-2232
Mailing address
1200 HUNTERS DR, STONE MOUNTAIN, GA 30083-2545
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DN014782
GA
Other
Enumeration date
06/27/2014
Last updated
06/27/2014
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