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General NPI Number Information
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NPI Number | 1750073615
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Entity Type | Organization
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Legal Business Name | IDEAL SMILE DENTISTRY LLC
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 05/30/2023
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Provider Practice Location Address
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Address Line | 2979 N LAKE PKWY STE 100
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City | COLUMBUS
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State | GA
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Zip | 31909-2575
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Country | US
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Telephone | 678-910-1716
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Fax |
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Provider Business Mailing Address
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Address Line | 3915 PIEDMONT LAKE RD
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City | PINE MOUNTAIN
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State | GA
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Zip | 31822-3558
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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 | SETH WALDEN
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Credential |
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Telephone | 678-910-1716
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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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