MEDICARE: SMILES OF DECATUR 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	122300000X	Dentist	013549	GA

General Provider Information

NPI Number	:	1780036848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES OF DECATUR P.C.

Provider Business Mailing Address
First Line	:	2458 WESLEY CHAPEL RD STE B
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-3423
Country	:	US
Telephone Number	:	770-322-0059
Fax Number	:

Provider Business Practice Location Address
First Line	:	2458 WESLEY CHAPEL RD STE B
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-3423
Country	:	US
Telephone Number	:	770-322-0059
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MAUZARD BENJAMIN
Credential	:
Telephone Number	:	770-322-0059

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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