Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DN011276 | GA |
NPI | 1134262777 |
---|---|
Provider Name | Dr. George Quintero |
First Address | Dacula, GA 30019 |
Second Address | Dacula, GA 30019-1662 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2007 |
Last Update Date | 08/07/2007 |