Healthcare Provider Details

I. General information

NPI: 1992101539
Provider Name (Legal Business Name): SMOKE RISE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 LILBURN STONE MOUNTAIN RD STE A
STONE MOUNTAIN GA
30087-2873
US

IV. Provider business mailing address

5500 LILBURN STONE MOUNTAIN RD STE A
STONE MOUNTAIN GA
30087-2873
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-5500
  • Fax: 770-559-9295
Mailing address:
  • Phone: 770-923-5500
  • Fax: 770-559-9295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013813
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JORDAN ROGERS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 470-801-4637