Provider Demographics
NPI:1417260670
Name:SMILE CENTER OF DALTON LLC
Entity Type:Organization
Organization Name:SMILE CENTER OF DALTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-513-1573
Mailing Address - Street 1:510 S KEELER WOODS DR NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2027
Mailing Address - Country:US
Mailing Address - Phone:404-513-1573
Mailing Address - Fax:770-452-3678
Practice Address - Street 1:328 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8680
Practice Address - Country:US
Practice Address - Phone:706-279-1802
Practice Address - Fax:706-279-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA590023714AMedicaid