MEDICARE: SOUTHERN SMILES FAMILY DENTISTRY, INC.

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	DN012623	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1548362718	OTHER	GA	INDIVIDUAL NPI #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720395924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN SMILES FAMILY DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	475 BILL KENNEDY WAY SE
Second Line	:	SUITE D & E
City	:	ATLANTA
State	:	GA
Zip	:	30316-6847
Country	:	US
Telephone Number	:	404-622-0622
Fax Number	:	404-622-0624

Provider Business Practice Location Address
First Line	:	475 BILL KENNEDY WAY SE
Second Line	:	SUITE D & E
City	:	ATLANTA
State	:	GA
Zip	:	30316-6847
Country	:	US
Telephone Number	:	404-622-0622
Fax Number	:	404-622-0624

Authorized Official
Title or Position	:	DENTIST
Name	:	GENISE A EVANS
Credential	:	DDS
Telephone Number	:	404-622-0622

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	09/09/2010

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