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General NPI Number Information
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NPI Number | 1811186398
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Entity Type | Organization
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Legal Business Name | AUSTELL COSMETIC DENTISTRY
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Dates
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Enumeration Date | 10/19/2007
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Last Update Date | 10/19/2007
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Provider Practice Location Address
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Address Line | 4760 AUSTELL RD SUITE 2
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City | AUSTELL
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State | GA
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Zip | 30106-2007
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Country | US
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Telephone | 770-941-9995
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Fax |
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Provider Business Mailing Address
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Address Line | 4760 AUSTELL RD SUITE 2
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City | AUSTELL
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State | GA
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Zip | 30106-2007
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Country | US
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Telephone | 770-941-9995
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Fax |
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Authorized Official
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Title or Position | PRESIDENT & CHIEF SMILE ARCHITECT
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Name | DR. ANISA LEE HAILEY
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Credential | D.M.D.
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Telephone | 770-941-9995
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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 | DN012026
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License Number State | GA
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