NPIMap

Organization Active NPI

Ga Southern Dental LLC

Doing business as MidCIty Dentistry

  • Dentist
  • Atlanta, GA
National Provider Identifier
1346068806
Registry record updated Oct 2, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
GA SOUTHERN DENTAL LLC
Doing business as
MidCIty Dentistry
Practice address
845 Spring St NW Ste B1
Atlanta, GA 30308-1051
Phone
(404) 685-3100
NPI assigned
Oct 2, 2024
Last updated
Oct 2, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
GA SOUTHERN DENTAL LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 2, 2024

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

845 Spring St NW Ste B1
Atlanta, GA 30308-1051

Mailing address

5830 Granite Pkwy Ste 780
Plano, TX 75024-6775

Other names 1

  • MidCIty Dentistry 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.

Locations

845 Spring St NW
Ste B1
Atlanta, GA 30308
Phone (404) 685-3100

5830 Granite Pkwy
Ste 780
Plano, TX 75024

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1727827200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727827200000",
    "number": "1346068806",
    "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": "845 SPRING ST NW STE B1",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303081051",
            "telephone_number": "404-685-3100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GA SOUTHERN DENTAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GA SOUTHERN DENTAL LLC",
        "enumeration_date": "2024-10-02",
        "last_updated": "2024-10-02",
        "certification_date": "2024-10-02",
        "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": "MidCIty Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Atlanta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2024; 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.