MEDICARE: SMILE ENVY PC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN012798	GA

General Provider Information

NPI Number	:	1396167391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE ENVY PC

Provider Business Mailing Address
First Line	:	4300 PACES FERRY RD SE
Second Line	:	SUITE 333
City	:	ATLANTA
State	:	GA
Zip	:	30339-5703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 PACES FERRY RD SE
Second Line	:	SUITE 333
City	:	ATLANTA
State	:	GA
Zip	:	30339-5703
Country	:	US
Telephone Number	:	281-566-2554
Fax Number	:	281-271-8617

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID LOFTERS
Credential	:	D.D.S.
Telephone Number	:	202-422-8116

Provider Enumeration Date	:	01/09/2014
Last Update Date	:	01/09/2014

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