MEDICARE: SMILE 23 GEORGIA 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1972263119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE 23 GEORGIA LLC

Provider Business Mailing Address
First Line	:	2265 CASCADE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2861
Country	:	US
Telephone Number	:	404-755-8539
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 CASCADE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2861
Country	:	US
Telephone Number	:	404-755-8539
Fax Number	:

Authorized Official
Title or Position	:	CDO
Name	:	TREVOR TUNE
Credential	:
Telephone Number	:	636-233-1882

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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