MEDICARE: I HEART DENTAL LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1306488838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I HEART DENTAL LLC

Provider Business Mailing Address
First Line	:	135 GOSHEN ROAD
Second Line	:	SUITE 205
City	:	RINCON
State	:	GA
Zip	:	31326-5546
Country	:	US
Telephone Number	:	912-499-1133
Fax Number	:	912-348-5806

Provider Business Practice Location Address
First Line	:	135 GOSHEN ROAD
Second Line	:	SUITE 205
City	:	RINCON
State	:	GA
Zip	:	31326-5546
Country	:	US
Telephone Number	:	912-499-1133
Fax Number	:	912-348-5806

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. MISTY MAE DEALE
Credential	:	DMD
Telephone Number	:	912-499-1133

Provider Enumeration Date	:	10/16/2019
Last Update Date	:	10/16/2019

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Directions to “I HEART DENTAL LLC ” Practice Location

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