Provider Demographics
NPI:1871703553
Name:PEACHTREE DENTAL GROUP
Entity type:Organization
Organization Name:PEACHTREE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-521-1978
Mailing Address - Street 1:3590 OLD MILTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-521-1978
Mailing Address - Fax:770-521-9936
Practice Address - Street 1:3590 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4465
Practice Address - Country:US
Practice Address - Phone:770-521-1978
Practice Address - Fax:770-521-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA113761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty