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General NPI Number Information
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NPI Number | 1619788676
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Entity Type | Organization
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Legal Business Name | SOUTHERN SMILES ORTHODONTICS, LLC
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Dates
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Enumeration Date | 01/17/2025
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Last Update Date | 01/17/2025
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Provider Practice Location Address
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Address Line | 7475 DOUGLAS BLVD STE 201
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-1519
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Country | US
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Telephone | 770-942-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 7475 DOUGLAS BLVD STE 201
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-1519
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PAYOR RELATIONS MANAGER
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Name | CASSANDRA WIETH
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Credential |
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Telephone | 440-563-8819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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