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General NPI Number Information
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NPI Number | 1770613119
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Entity Type | Organization
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Legal Business Name | BUCKHEAD SMILES COSMETIC AND FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 321 PHARR RD NE SUITE A
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City | ATLANTA
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State | GA
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Zip | 30305-2346
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Country | US
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Telephone | 404-917-1111
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Fax | 404-917-1113
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Provider Business Mailing Address
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Address Line | 321 PHARR RD NE SUITE A
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City | ATLANTA
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State | GA
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Zip | 30305-2346
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Country | US
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Telephone | 404-917-1111
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Fax | 404-917-1113
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. PORTIA MAXINE GRAYSON
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Credential | DDS
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Telephone | 404-917-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN012800
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License Number State | GA
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