=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720395924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN SMILES FAMILY DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2010
-----------------------------------------------------
Last Update Date | 09/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 BILL KENNEDY WAY SE SUITE D & E
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-622-0622
-----------------------------------------------------
Fax | 404-622-0624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 475 BILL KENNEDY WAY SE SUITE D & E
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-622-0622
-----------------------------------------------------
Fax | 404-622-0624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | GENISE A EVANS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 404-622-0622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN012623
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------