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General NPI Number Information
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NPI Number | 1740984574
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Entity Type | Organization
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Legal Business Name | GREAT SMILES BUFORD CENTER LLC
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Dates
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Enumeration Date | 03/27/2023
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Last Update Date | 03/27/2023
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Provider Practice Location Address
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Address Line | 1879 BUFORD HWY STE 5A
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City | BUFORD
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State | GA
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Zip | 30518-3628
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Country | US
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Telephone | 470-722-5591
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Fax |
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Provider Business Mailing Address
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Address Line | 2055 BARRETT LAKES BLVD # 822
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City | KENNESAW
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State | GA
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Zip | 30144-8003
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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 | CEO
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Name | DR. BEVERLY ZIDOR
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Credential | DDS
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Telephone | 772-828-9005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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