Provider Demographics
NPI:1235589995
Name:LAKE LANIER SMILES
Entity Type:Organization
Organization Name:LAKE LANIER SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDIPATI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-966-7766
Mailing Address - Street 1:4965 LANIER ISLANDS PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1700
Mailing Address - Country:US
Mailing Address - Phone:770-831-0559
Mailing Address - Fax:
Practice Address - Street 1:4965 LANIER ISLANDS PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1700
Practice Address - Country:US
Practice Address - Phone:770-831-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental