MEDICARE: FABULOUS SMILES P.C.

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	DN011947	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	:	1982930806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FABULOUS SMILES P.C.

Provider Business Mailing Address
First Line	:	1188 RALPH DAVID ABERNATHY BLVD SW STE 101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1754
Country	:	US
Telephone Number	:	404-767-9356
Fax Number	:	404-529-4465

Provider Business Practice Location Address
First Line	:	1188 RALPH DAVID ABERNATHY BLVD SW STE 101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1754
Country	:	US
Telephone Number	:	404-767-9356
Fax Number	:	404-529-4465

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALDOUS WILSON
Credential	:
Telephone Number	:	404-767-9356

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	10/28/2009

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