Provider Demographics
NPI:1205211133
Name:FABULOUS SMILES OF LILBURN
Entity Type:Organization
Organization Name:FABULOUS SMILES OF LILBURN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-557-0788
Mailing Address - Street 1:331 ARCADO RD NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3077
Mailing Address - Country:US
Mailing Address - Phone:770-557-0788
Mailing Address - Fax:404-420-2951
Practice Address - Street 1:331 ARCADO RD NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3077
Practice Address - Country:US
Practice Address - Phone:770-557-0788
Practice Address - Fax:404-420-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011973305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service