Life Bridge Dental Ga LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

LIFE BRIDGE DENTAL GA LLC

Practice address

675 Ponce de Leon Ave NE
Atlanta, GA 30308-1884

Phone

(212) 686-3686

Fax

(615) 468-0325

NPI assigned

Nov 9, 2021

Last updated

Nov 9, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Kenneth Neil Sullivan

Title

Director RCM

Phone

(615) 601-5250

Specialties & licenses 2

Addresses

Locations

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

{
    "created_epoch": "1636416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1636416000000",
    "number": "1609532126",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8 CITY BLVD STE 203",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372092559",
            "telephone_number": "212-686-3686",
            "fax_number": "615-468-0325"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "675 PONCE DE LEON AVE NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303081884",
            "telephone_number": "212-686-3686",
            "fax_number": "615-468-0325"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFE BRIDGE DENTAL GA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-09",
        "last_updated": "2021-11-09",
        "certification_date": "2021-11-09",
        "status": "A",
        "authorized_official_last_name": "SULLIVAN",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "NEIL",
        "authorized_official_title_or_position": "DIRECTOR RCM",
        "authorized_official_telephone_number": "615-601-5250"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Dentist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2021; 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.