MEDICARE: MID AMERICA GROUP OF GEORGIA 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	:	1306280458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID AMERICA GROUP OF GEORGIA PC

Provider Business Mailing Address
First Line	:	1499 WINDHORST WAY
Second Line	:	STE 100
City	:	GREENWOOD
State	:	IN
Zip	:	46143-8800
Country	:	US
Telephone Number	:	317-886-6639
Fax Number	:	888-547-0377

Provider Business Practice Location Address
First Line	:	160 CLAIREMONT AVE
Second Line	:	STE 200
City	:	DECATUR
State	:	GA
Zip	:	30030-2546
Country	:	US
Telephone Number	:	317-886-6637
Fax Number	:	888-547-0377

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEWEL BERNADETTE SMITH
Credential	:	DDS
Telephone Number	:	317-886-6639

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	03/19/2014

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