=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013718873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMYRNA DENTAL SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2025
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3240 S COBB DR SE STE 100
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-4180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-801-1641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2705 AZALEA BLUFF DR
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-966-7766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PRAVEEN R GUDIPATI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 404-966-7766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------