Provider Demographics
NPI:1265002703
Name:SOUTHERN SMILES DENTISTRY CUMMING PC
Entity Type:Organization
Organization Name:SOUTHERN SMILES DENTISTRY CUMMING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:470-253-1747
Mailing Address - Street 1:1475 PEACHTREE PKWY STE C3
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9793
Mailing Address - Country:US
Mailing Address - Phone:470-253-1747
Mailing Address - Fax:
Practice Address - Street 1:1475 PEACHTREE PKWY STE C3
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9793
Practice Address - Country:US
Practice Address - Phone:470-253-1747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1225310592OtherPPO