MEDICARE: FABULOUS SMILES OF ATLANTA 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	305R00000X	Preferred Provider Organization	011973	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962660555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FABULOUS SMILES OF ATLANTA LLC

Provider Business Mailing Address
First Line	:	1188 RALPH DAVID ABERNATHY BLVD SW
Second Line	:	SUITE 101
City	:	ATLANTA
State	:	GA
Zip	:	30310-1754
Country	:	US
Telephone Number	:	404-758-0770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1188 RALPH DAVID ABERNATHY BLVD SW
Second Line	:	SUITE 101
City	:	ATLANTA
State	:	GA
Zip	:	30310-1754
Country	:	US
Telephone Number	:	404-758-0770
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIELLE DENISE GREENE
Credential	:	DDS
Telephone Number	:	404-758-0770

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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