MEDICARE: FABULOUS SMILES P.C.

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	DN011947	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619140928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FABULOUS SMILES P.C.

Provider Business Mailing Address
First Line	:	8737 DUNWOODY PLACE SUITE #3
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350
Country	:	US
Telephone Number	:	678-206-0199
Fax Number	:	404-529-4465

Provider Business Practice Location Address
First Line	:	8737 DUNWOODY PL STE 3
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350-2985
Country	:	US
Telephone Number	:	678-206-0199
Fax Number	:	404-529-4465

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALDOUS WILSON
Credential	:	D.D.S.
Telephone Number	:	678-206-0199

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	04/08/2008

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