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General NPI Number Information
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NPI Number | 1811516479
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Entity Type | Organization
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Legal Business Name | MOUTHPEACE DENTAL 4, LLC
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Dates
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Enumeration Date | 04/14/2020
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Last Update Date | 04/14/2020
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Provider Practice Location Address
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Address Line | 541 FOREST PKWY STE 18
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City | FOREST PARK
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State | GA
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Zip | 30297-6110
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Country | US
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Telephone | 404-228-6801
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Fax |
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Provider Business Mailing Address
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Address Line | 2149 BRANNEN RD SE
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City | ATLANTA
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State | GA
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Zip | 30316-4117
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Country | US
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Telephone | 312-371-1423
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Fax |
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Authorized Official
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Title or Position | OWNER /DENTIST
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Name | DR. SYRETTA WELLS
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Credential | DDS
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Telephone | 312-371-1423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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