MEDICARE: S23 OF GEORGIA, 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	122300000X	Dentist

General Provider Information

NPI Number	:	1578415113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S23 OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	2265 CASCADE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2861
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 CASCADE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2861
Country	:	US
Telephone Number	:	404-753-4753
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	MS. DEWONNA LEWIS
Credential	:
Telephone Number	:	404-246-9567

Provider Enumeration Date	:	02/13/2026
Last Update Date	:	03/10/2026

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