MEDICARE: GEORGIA DENTAL GROUP OF GA LLC

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
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1760202816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DENTAL GROUP OF GA LLC

Provider Business Mailing Address
First Line	:	2300 LAKEVIEW PKWY STE 250
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-3954
Country	:	US
Telephone Number	:	470-207-3264
Fax Number	:

Provider Business Practice Location Address
First Line	:	592 MEDICAL PARK DR STE B
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-2055
Country	:	US
Telephone Number	:	770-863-7324
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BRIAN SMITH
Credential	:
Telephone Number	:	470-207-3264

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	05/20/2026

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