MEDICARE: SOUTH HAIRSTON FAMILY DENTISTRY

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	10982	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598817488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH HAIRSTON FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	1234 S HAIRSTON RD
Second Line	:	SUITE 23
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2749
Country	:	US
Telephone Number	:	404-294-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 S HAIRSTON RD
Second Line	:	SUITE 23
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2749
Country	:	US
Telephone Number	:	404-294-3600
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. HEATHER ALLEN
Credential	:	D.D.S.
Telephone Number	:	404-294-3600

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	09/17/2008

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