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General NPI Number Information
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NPI Number | 1942606645
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Entity Type | Organization
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Legal Business Name | MOUTHPEACE DENTAL LLC
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Dates
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Enumeration Date | 11/07/2014
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Last Update Date | 11/07/2014
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Provider Practice Location Address
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Address Line | 1050 MARIETTA ST NW SUITE A
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City | ATLANTA
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State | GA
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Zip | 30318-5522
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Country | US
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Telephone | 312-371-1423
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Fax |
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Provider Business Mailing Address
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Address Line | 1050 MARIETTA ST NW SUITE A
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City | ATLANTA
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State | GA
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Zip | 30318-5522
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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 | DENTIST
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Name | 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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN013505
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DN013505
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN013505
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License Number State | GA
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