MEDICARE: ORTHODONTIC CARE OF GEORGIA

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	011309	GA

General Provider Information

NPI Number	:	1962636977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHODONTIC CARE OF GEORGIA

Provider Business Mailing Address
First Line	:	1828 JONESBORO RD
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5960
Country	:	US
Telephone Number	:	678-432-8505
Fax Number	:	678-432-9419

Provider Business Practice Location Address
First Line	:	3680 CASCADE RD SW
Second Line	:	SUITE B
City	:	ATLANTA
State	:	GA
Zip	:	30331-2168
Country	:	US
Telephone Number	:	404-691-4848
Fax Number	:	404-691-5631

Authorized Official
Title or Position	:	MANAGER
Name	:	ROBERT ZAYAS
Credential	:
Telephone Number	:	706-342-7272

Provider Enumeration Date	:	05/05/2009
Last Update Date	:	05/05/2009

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