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General NPI Number Information
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NPI Number | 1780036848
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Entity Type | Organization
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Legal Business Name | SMILES OF DECATUR P.C.
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Dates
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Enumeration Date | 07/12/2016
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Last Update Date | 07/12/2016
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Provider Practice Location Address
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Address Line | 2458 WESLEY CHAPEL RD STE B
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City | DECATUR
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State | GA
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Zip | 30035-3423
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Country | US
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Telephone | 770-322-0059
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Fax |
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Provider Business Mailing Address
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Address Line | 2458 WESLEY CHAPEL RD STE B
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City | DECATUR
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State | GA
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Zip | 30035-3423
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Country | US
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Telephone | 770-322-0059
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MAUZARD BENJAMIN
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Credential |
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Telephone | 770-322-0059
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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 | 013549
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License Number State | GA
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