MEDICARE: CREATIVE DENTISTRY OF ATLANTA

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	DN012610	GA

General Provider Information

NPI Number	:	1801389812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE DENTISTRY OF ATLANTA

Provider Business Mailing Address
First Line	:	5505 PEACHTREE DUNWOODY ROAD
Second Line	:	SUITE 460
City	:	ATLANTA
State	:	GA
Zip	:	30342
Country	:	US
Telephone Number	:	404-883-3287
Fax Number	:	404-883-3289

Provider Business Practice Location Address
First Line	:	5505 PEACHTREE DUNWOODY ROAD
Second Line	:	SUITE 460
City	:	ATLANTA
State	:	GA
Zip	:	30342
Country	:	US
Telephone Number	:	404-883-3287
Fax Number	:	404-883-3289

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	DR. ANITHA R REDDY
Credential	:	DMD
Telephone Number	:	404-883-3287

Provider Enumeration Date	:	06/13/2018
Last Update Date	:	06/13/2018

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