MEDICARE: KOOL SMILES SC-2, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1568775468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOL SMILES SC-2, PC

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE STE 150
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6407
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5422 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29206-5412
Country	:	US
Telephone Number	:	800-920-9948
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID VIETH
Credential	:	DDS
Telephone Number	:	770-916-5028

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	12/18/2014

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