MEDICARE: GA SDS III 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	1223P0221X	Pediatric Dentistry
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1508639535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GA SDS III PC

Provider Business Mailing Address
First Line	:	401 CHURCH ST STE 1400
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37219-2214
Country	:	US
Telephone Number	:	504-638-0303
Fax Number	:

Provider Business Practice Location Address
First Line	:	91 W WIEUCA RD NE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-3248
Country	:	US
Telephone Number	:	404-303-7400
Fax Number	:

Authorized Official
Title or Position	:	DIREC OF CRED AND PROV REL
Name	:	CHARLOTTE E VIAL
Credential	:
Telephone Number	:	504-638-0303

Provider Enumeration Date	:	11/01/2023
Last Update Date	:	11/01/2023

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Directions to “GA SDS III PC ” Practice Location

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