MEDICARE: DR. PONNIE DAVIS POISAL DMD

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	011261	GA

General Provider Information

NPI Number	:	1679577936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PONNIE DAVIS POISAL DMD

Provider Business Mailing Address
First Line	:	3973 ATLANTA HWY
Second Line	:	STE 100
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3750
Country	:	US
Telephone Number	:	770-466-3114
Fax Number	:	770-466-3777

Provider Business Practice Location Address
First Line	:	3973 ATLANTA HWY
Second Line	:	STE 100
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3750
Country	:	US
Telephone Number	:	770-466-3114
Fax Number	:	770-466-3777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	07/08/2007

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