Healthcare Provider Details

I. General information

NPI: 1710435763
Provider Name (Legal Business Name): GWINNETT SMILE DESIGN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 OLD NORCROSS RD SUITE B
LAWRENCEVILLE GA
30046-4315
US

IV. Provider business mailing address

603 OLD NORCROSS RD SUITE B
LAWRENCEVILLE GA
30046-4315
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-9990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN14715
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014749
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH003931
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH005357
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN014749
License Number StateGA

VIII. Authorized Official

Name: KATLYNN PITTMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-995-9990