=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245483882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR SMILE FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 07/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3931 HIGHWAY 78 W SUITE A
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-985-1050
-----------------------------------------------------
Fax | 800-985-8967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3931 HWY 78 SUITE A
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-985-1050
-----------------------------------------------------
Fax | 800-985-8967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HEATHER ALLEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 770-985-1050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------