=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679969380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DENTAL ARTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2015
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4705 NORTHSIDE DR SUITE 100
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-207-6939
-----------------------------------------------------
Fax | 478-254-9638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4705 NORTHSIDE DR SUITE 100
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-207-6939
-----------------------------------------------------
Fax | 478-254-9638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SAMER MUFID OTHMAN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 478-207-6939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN014686
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------