MEDICARE: EVOLUTION DENTAL SURGERY AND AESTHETIC CENTERS

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

General Provider Information

NPI Number	:	1063095842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLUTION DENTAL SURGERY AND AESTHETIC CENTERS

Provider Business Mailing Address
First Line	:	3775 VENTURE DR STE 101
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-5102
Country	:	US
Telephone Number	:	470-387-0385
Fax Number	:	678-550-4999

Provider Business Practice Location Address
First Line	:	3775 VENTURE DR STE 101
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-5102
Country	:	US
Telephone Number	:	470-387-0385
Fax Number	:	678-550-4999

Authorized Official
Title or Position	:	PROSTHODONTIST
Name	:	DR. AMY CAMBA
Credential	:	DMD
Telephone Number	:	706-951-3147

Provider Enumeration Date	:	04/30/2021
Last Update Date	:	04/30/2021

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