Healthcare Provider Details

I. General information

NPI: 1942606645
Provider Name (Legal Business Name): MOUTHPEACE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2014
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 MARIETTA ST NW SUITE A
ATLANTA GA
30318-5522
US

IV. Provider business mailing address

1050 MARIETTA ST NW SUITE A
ATLANTA GA
30318-5522
US

V. Phone/Fax

Practice location:
  • Phone: 312-371-1423
  • Fax:
Mailing address:
  • Phone: 312-371-1423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013505
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013505
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN013505
License Number StateGA

VIII. Authorized Official

Name: SYRETTA WELLS
Title or Position: DENTIST
Credential: DDS
Phone: 312-371-1423