MEDICARE: ATL CENTER FOR COSMETIC DENTISTRY LLC

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

General Provider Information

NPI Number	:	1821771262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATL CENTER FOR COSMETIC DENTISTRY LLC

Provider Business Mailing Address
First Line	:	5014 ROSWELL RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-2207
Country	:	US
Telephone Number	:	404-847-9711
Fax Number	:

Provider Business Practice Location Address
First Line	:	5014 ROSWELL RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-2207
Country	:	US
Telephone Number	:	404-847-9711
Fax Number	:

Authorized Official
Title or Position	:	VP INSURANCE PLAN MANAGEMENT
Name	:	MICHAEL COLE
Credential	:
Telephone Number	:	727-424-2990

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	08/11/2023

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