NPIMap

Organization Active NPI

Ga Sothern Dental PPO

  • Dentist
  • Marietta, GA
National Provider Identifier
1750117537
Registry record updated Sep 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
GA SOTHERN DENTAL PPO
Practice address
3911 Mary Eliza Trce NW Ste 100
Marietta, GA 30064-1087
Phone
(770) 362-6417
NPI assigned
Sep 10, 2024
Organization subpart
Yes
Parent organization
GA SOTHERN DENTAL PPOAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 10, 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

3911 Mary Eliza Trce NW Ste 100
Marietta, GA 30064-1087

Mailing address

5830 Granite Pkwy Ste 780
Plano, TX 75024-6775
Phone (469) 596-6137

Other names 1

  • Natural Smiles Dentistry Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Ga Sothern Dental PPO7 organizations share this tax ID, including this one
Part of
Ga Sothern Dental PPO

Other organizations with this tax ID 6

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

Locations

3911 Mary Eliza Trce NW
Ste 100
Marietta, GA 30064
Phone (770) 362-6417

NPI Registry JSON

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

{
    "created_epoch": "1725926400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1725926400000",
    "number": "1750117537",
    "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",
            "telephone_number": "469-596-6137"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3911 MARY ELIZA TRCE NW STE 100",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300641087",
            "telephone_number": "770-362-6417"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GA SOTHERN DENTAL PPO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GA SOTHERN DENTAL PPO",
        "enumeration_date": "2024-09-10",
        "last_updated": "2024-09-10",
        "certification_date": "2024-09-10",
        "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": "Natural Smiles Dentistry",
            "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 Sep 10, 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.