MEDICARE: MR. DAN MARTIN SMYLY OPTICIAN

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	156FX1800X	Optician	983	GA

General Provider Information

NPI Number	:	1801916812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAN MARTIN SMYLY OPTICIAN

Provider Business Mailing Address
First Line	:	4765 MEMORIAL DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-1417
Country	:	US
Telephone Number	:	404-296-2307
Fax Number	:	404-296-0850

Provider Business Practice Location Address
First Line	:	4765 MEMORIAL DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-1417
Country	:	US
Telephone Number	:	404-296-2307
Fax Number	:	404-296-0850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	07/08/2007

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