=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609170158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUCKHEAD SMILE CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2010
-----------------------------------------------------
Last Update Date | 12/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 PEACHTREE RD NW SUITE 209
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-261-0909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 PEACHTREE RD NW SUITE 209
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | LORI SPENCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-312-5167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------