MEDICARE: GLOWING SMILES PEDIATRIC 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1528773538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOWING SMILES PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	375 BIG CREEK LN
Second Line	:
City	:	RINGGOLD
State	:	GA
Zip	:	30736-8562
Country	:	US
Telephone Number	:	423-400-8923
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019 BEATY BLVD STE 600
Second Line	:
City	:	GALLATIN
State	:	TN
Zip	:	37066-4765
Country	:	US
Telephone Number	:	615-989-6611
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. BORA KIM
Credential	:	DMD
Telephone Number	:	423-400-8923

Provider Enumeration Date	:	01/16/2023
Last Update Date	:	01/16/2023

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