MEDICARE: SOPHIA WAYE COLEY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8731	GA

General Provider Information

NPI Number	:	1033324751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA WAYE COLEY DMD

Provider Business Mailing Address
First Line	:	PO BOX 961480
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-6906
Country	:	US
Telephone Number	:	770-991-9925
Fax Number	:

Provider Business Practice Location Address
First Line	:	653 ROBERTS DR STE B
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2959
Country	:	US
Telephone Number	:	770-991-9925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	12/16/2015

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