MEDICARE: DR. C CORNELIOUS SLATON

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	1223E0200X	Endodontics	DN010609	GA

General Provider Information

NPI Number	:	1942212246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. C CORNELIOUS SLATON

Provider Business Mailing Address
First Line	:	3459 ACWORTH DUE WEST RD NW
Second Line	:	SUITE 305
City	:	ACWORTH
State	:	GA
Zip	:	30101-5819
Country	:	US
Telephone Number	:	770-975-0175
Fax Number	:	770-975-7294

Provider Business Practice Location Address
First Line	:	3459 ACWORTH DUE WEST RD NW
Second Line	:	SUITE 305
City	:	ACWORTH
State	:	GA
Zip	:	30101-5819
Country	:	US
Telephone Number	:	770-975-0175
Fax Number	:	770-975-7294

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	07/08/2007

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