MEDICARE: ATLANTA WEST PERIODONTICS AND DENTAL IMPLANTS 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	122300000X	Dentist	2901016263	MI
2	122300000X	Dentist	10752	GA

General Provider Information

NPI Number	:	1700977360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTA WEST PERIODONTICS AND DENTAL IMPLANTS PC

Provider Business Mailing Address
First Line	:	2168 SKYVIEW DRIVE
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122
Country	:	US
Telephone Number	:	770-739-5097
Fax Number	:	770-739-0517

Provider Business Practice Location Address
First Line	:	2168 SKYVIEW DRIVE
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122
Country	:	US
Telephone Number	:	770-739-5097
Fax Number	:	770-739-0517

Authorized Official
Title or Position	:	OWNER CEO
Name	:	DR. CHERYL LYNN CUSHMAN
Credential	:	DDS
Telephone Number	:	770-739-5097

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	03/07/2023

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