Healthcare Provider Details

I. General information

NPI: 1982258968
Provider Name (Legal Business Name): SMILE WIT CONFIDENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 TARA BLVD
JONESBORO GA
30236-1214
US

IV. Provider business mailing address

6465 TARA BLVD
JONESBORO GA
30236-1214
US

V. Phone/Fax

Practice location:
  • Phone: 770-629-6222
  • Fax: 678-672-3131
Mailing address:
  • Phone: 770-629-6222
  • Fax: 678-672-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKY MUNOZ
Title or Position: GENERAL MANAGER
Credential:
Phone: 770-629-6222