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General NPI Number Information
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NPI Number | 1992077804
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Entity Type | Organization
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Legal Business Name | BEAUTIFUL SMILES OF COLLEGE PARK LLC
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Dates
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Enumeration Date | 02/08/2012
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Last Update Date | 02/08/2012
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Provider Practice Location Address
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Address Line | 6175 OLD NATIONAL HWY STE 430
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City | ATLANTA
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State | GA
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Zip | 30349-4470
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Country | US
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Telephone | 770-907-2666
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Fax |
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Provider Business Mailing Address
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Address Line | 6175 OLD NATIONAL HWY STE 430
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City | ATLANTA
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State | GA
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Zip | 30349-4470
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Country | US
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Telephone | 770-907-2666
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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. PAUL R MCKOY
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Credential | DDS
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Telephone | 678-517-8368
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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 | DN012765
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License Number State | GA
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