Provider Demographics
NPI:1073944997
Name:COSMETIC FAMILY & IMPLANT DENTISTRY OF ATLANTA
Entity Type:Organization
Organization Name:COSMETIC FAMILY & IMPLANT DENTISTRY OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANSOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-441-2565
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE
Mailing Address - Street 2:SUITE 2120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6401
Mailing Address - Country:US
Mailing Address - Phone:770-955-2505
Mailing Address - Fax:770-953-4011
Practice Address - Street 1:3350 RIVERWOOD PKWY SE
Practice Address - Street 2:SUITE 2120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-6401
Practice Address - Country:US
Practice Address - Phone:770-955-2505
Practice Address - Fax:770-953-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012848305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service