MEDICARE: KOOL SMILES PTC 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	1223G0001X	General Practice Dentistry	DN011874	GA

General Provider Information

NPI Number	:	1689877557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOL SMILES PTC PC

Provider Business Mailing Address
First Line	:	400 GALLERIA PKWY SE
Second Line	:	SUITE 800
City	:	ATLANTA
State	:	GA
Zip	:	30339-5980
Country	:	US
Telephone Number	:	678-904-5665
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 GALLERIA PKWY SE
Second Line	:	SUITE 800
City	:	ATLANTA
State	:	GA
Zip	:	30339-5980
Country	:	US
Telephone Number	:	678-904-5665
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DALE GARY MAYFIELD
Credential	:	DMD
Telephone Number	:	678-904-5665

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	08/22/2020

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