NPIMap

Organization Active NPI

Ga Southern Dental LLC

  • Dentist
  • Marietta, GA
National Provider Identifier
1255285607
Registry record updated Feb 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
GA SOUTHERN DENTAL LLC
Practice address
1225 Johnson Ferry Rd Ste 660
Marietta, GA 30068-2772
Phone
(770) 973-6494
NPI assigned
Feb 23, 2026
Organization subpart
Yes
Parent organization
GA SOUTHERN DENTAL LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 23, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Erika Melissa Menjivar
Title
Sr. Credentialing Specialist
Phone
(469) 596-6137

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X Primary

Addresses

Primary practice location

1225 Johnson Ferry Rd Ste 660
Marietta, GA 30068-2772

Mailing address

5830 Granite Pkwy Ste 780
Plano, TX 75024-6775

Other names 1

  • Georgia Dental Medicine Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Ga Southern Dental LLC7 organizations share this tax ID, including this one
Part of
Ga Southern Dental LLC

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1771804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1771804800000",
    "number": "1255285607",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5830 GRANITE PKWY STE 780",
            "city": "PLANO",
            "state": "TX",
            "postal_code": "750246775"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1225 JOHNSON FERRY RD STE 660",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300682772",
            "telephone_number": "770-973-6494"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GA SOUTHERN DENTAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GA SOUTHERN DENTAL LLC",
        "enumeration_date": "2026-02-23",
        "last_updated": "2026-02-23",
        "certification_date": "2026-02-23",
        "status": "A",
        "authorized_official_last_name": "MENJIVAR",
        "authorized_official_first_name": "ERIKA",
        "authorized_official_middle_name": "MELISSA",
        "authorized_official_title_or_position": "SR. CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "469-596-6137"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Georgia Dental Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marietta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.