Healthcare Provider Details

I. General information

NPI: 1780429225
Provider Name (Legal Business Name): DESTINY JA'MECIA SMART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N ARCADIA AVE STE 151
DECATUR GA
30030-2177
US

IV. Provider business mailing address

1984 DECO DR
KENNESAW GA
30144-1899
US

V. Phone/Fax

Practice location:
  • Phone: 470-338-5352
  • Fax:
Mailing address:
  • Phone: 863-845-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124354
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: