NPI Record of CEDAR DENTAL CLINICAL I, LLC NPI 1003423039

Dentist (Orthodontics and Dentofacial Orthopedics) in Mcdonough, GA

Complete NPI Record

Field Name Value Definition
NPI1003423039The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code2Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EINUNAVAILThe Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
Provider Organization Name Legal Business NameCEDAR DENTAL CLINICAL I, LLCThe name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address6801 GOVERNORS LAKE PKWY STE 290The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City NamePEACHTREE CORNERSThe city name in the mailing address of the provider being identified.
Provider Business Mailing Address State NameGAThe State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code300711136The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S USThe country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number6789783099The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number6786914425The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address119 WILLOW LNThe first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City NameMCDONOUGHThe city name in the location address of the provider being identified.
Provider Business Practice Location Address State NameGAThe State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code302536574The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S USThe country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number6784328505The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number6784329419The fax number associated with the location address of the provider being identified.
Provider Enumeration Date9/24/2020The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date9/24/2020The date that a record was last updated or changed.
Authorized Official Last NameDALLAMThe last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First NameHENRYThe first name of the authorized official.
Authorized Official Middle NameRANKINThe middle name of the authorized official.
Authorized Official Title or PositionPRESIDENTThe title or position of the authorized official.
Authorized Official Telephone Number7703312529The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 11223X0400XCode designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1Y
Other Provider Identifier 1DN013071Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 101Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 1GA
Other Provider Identifier Issuer 1GA DENTAL LICENSE
Is Organization SubpartN
Authorized Official Name Prefix TextMR.
Authorized Official Name Suffix TextIII
Authorized Official Credential TextDMD
Healthcare Provider Taxonomy Group 1193400000X MULTIPLE SINGLE SPECIALTY GROUP
NPI Certification Date9/24/2020