MEDICARE: KING & MCCUNE ORTHODONTICS, 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1598173049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING & MCCUNE ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	3401 NORTHSIDE PARKWAY NW
Second Line	:	SUITE 200
City	:	ATLANTA
State	:	GA
Zip	:	30327-2316
Country	:	US
Telephone Number	:	404-233-1972
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 NORTHSIDE PARKWAY NW
Second Line	:	SUITE 200
City	:	ATLANTA
State	:	GA
Zip	:	30327-2316
Country	:	US
Telephone Number	:	404-233-1972
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. SUZANNE REYNAUD KING
Credential	:	D.D.S.
Telephone Number	:	404-233-1972

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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