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General NPI Number Information
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NPI Number | 1851961643
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Entity Type | Organization
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Legal Business Name | FULL SMILE DENTAL GEORGIA, PLLC
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Dates
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Enumeration Date | 06/25/2021
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Last Update Date | 06/25/2021
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Provider Practice Location Address
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Address Line | 3609 S GEORGIA ST
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City | AMARILLO
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State | TX
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Zip | 79109-4847
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Country | US
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Telephone | 806-641-1373
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Fax | 806-353-7077
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Provider Business Mailing Address
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Address Line | 5051 S SONCY RD
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City | AMARILLO
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State | TX
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Zip | 79119-6667
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Country | US
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Telephone | 806-641-1373
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Fax | 806-353-7077
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM EDWARD GRAVES
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Credential | DMD
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Telephone | 806-641-1373
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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 |
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License Number State |
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