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General NPI Number Information
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NPI Number | 1962660555
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Entity Type | Organization
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Legal Business Name | FABULOUS SMILES OF ATLANTA LLC
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 05/30/2008
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Provider Practice Location Address
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Address Line | 1188 RALPH DAVID ABERNATHY BLVD SW SUITE 101
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City | ATLANTA
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State | GA
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Zip | 30310-1754
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Country | US
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Telephone | 404-758-0770
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Fax |
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Provider Business Mailing Address
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Address Line | 1188 RALPH DAVID ABERNATHY BLVD SW SUITE 101
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City | ATLANTA
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State | GA
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Zip | 30310-1754
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Country | US
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Telephone | 404-758-0770
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DANIELLE DENISE GREENE
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Credential | DDS
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Telephone | 404-758-0770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 011973
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License Number State | GA
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