Healthcare Provider Details

I. General information

NPI: 1962660555
Provider Name (Legal Business Name): FABULOUS SMILES OF ATLANTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 RALPH DAVID ABERNATHY BLVD SW SUITE 101
ATLANTA GA
30310-1754
US

IV. Provider business mailing address

1188 RALPH DAVID ABERNATHY BLVD SW SUITE 101
ATLANTA GA
30310-1754
US

V. Phone/Fax

Practice location:
  • Phone: 404-758-0770
  • Fax:
Mailing address:
  • Phone: 404-758-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number011973
License Number StateGA

VIII. Authorized Official

Name: DR. DANIELLE DENISE GREENE
Title or Position: PRESIDENT
Credential: DDS
Phone: 404-758-0770