MEDICARE: IDEAL DENTAL POWERS PARK PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1184366023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL POWERS PARK PC

Provider Business Mailing Address
First Line	:	PO BOX 840925
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 TERRELL MILL RD SE STE 109
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6155
Country	:	US
Telephone Number	:	470-338-5354
Fax Number	:	470-646-5101

Authorized Official
Title or Position	:	OWNER
Name	:	RODNEY ALLES
Credential	:	DDS
Telephone Number	:	72-331-8079

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	10/02/2023

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