Healthcare Provider Details

I. General information

NPI: 1568947554
Provider Name (Legal Business Name): MODERN SMILES DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HIGHWAY 211 NW STE 6A
BRASELTON GA
30517-3403
US

IV. Provider business mailing address

2095 HIGHWAY 211 NW STE 6A
BRASELTON GA
30517-3403
US

V. Phone/Fax

Practice location:
  • Phone: 770-800-1044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: OLUYEMI WORKMAN
Title or Position: DENTIST
Credential: DDS
Phone: 770-800-1044