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General NPI Number Information
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NPI Number | 1073944997
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Entity Type | Organization
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Legal Business Name | COSMETIC FAMILY & IMPLANT DENTISTRY OF ATLANTA
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Dates
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Enumeration Date | 12/03/2013
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 3350 RIVERWOOD PKWY SE SUITE 2120
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City | ATLANTA
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State | GA
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Zip | 30339-6401
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Country | US
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Telephone | 770-955-2505
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Fax | 770-953-4011
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Provider Business Mailing Address
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Address Line | 3350 RIVERWOOD PKWY SE SUITE 2120
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City | ATLANTA
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State | GA
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Zip | 30339-6401
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Country | US
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Telephone | 770-955-2505
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Fax | 770-953-4011
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. MICHAEL S MANSOURI
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Credential | DMD
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Telephone | 267-441-2565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | DN012848
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License Number State | GA
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