MEDICARE: BENTWATER COSMETIC AND FAMILY DENTISTRY

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN011428	OTHER	GA	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1154069391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENTWATER COSMETIC AND FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	351 THORNTON RD STE 101
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-1589
Country	:	US
Telephone Number	:	770-944-9755
Fax Number	:	770-944-1261

Provider Business Practice Location Address
First Line	:	351 THORNTON RD STE 101
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-1589
Country	:	US
Telephone Number	:	770-944-9755
Fax Number	:	770-944-1261

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	TIFFANY THRELKELD
Credential	:	DO
Telephone Number	:	678-499-3514

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	07/27/2022

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Directions to “BENTWATER COSMETIC AND FAMILY DENTISTRY ” Practice Location

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