=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295263481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 7191 DDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7191 DOUGLAS BLVD STE A
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-4400
-----------------------------------------------------
Fax | 770-800-3523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7191 DOUGLAS BLVD STE A
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-4400
-----------------------------------------------------
Fax | 770-800-3523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | NIKKI ROLLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-452-1164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------