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General NPI Number Information
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NPI Number | 1134251648
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Entity Type | Organization
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Legal Business Name | SMILES DENTAL LAB, INC.
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Dates
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Enumeration Date | 03/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6030 HIGHWAY 85 STE 240
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City | RIVERDALE
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State | GA
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Zip | 30274-1535
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Country | US
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Telephone | 770-996-5737
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Fax | 770-996-5916
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Provider Business Mailing Address
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Address Line | 6030 HIGHWAY 85 STE 240
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City | RIVERDALE
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State | GA
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Zip | 30274-1535
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Country | US
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Telephone | 770-996-5737
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Fax | 770-996-5916
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Authorized Official
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Title or Position | DENTIST
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Name | KENNETH F. FLEET
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Credential | DDS
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Telephone | 770-996-5737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9925
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License Number State | GA
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