Provider Demographics
NPI:1457499642
Name:GREAT SMILE DENTAL
Entity Type:Organization
Organization Name:GREAT SMILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPRITI
Authorized Official - Middle Name:
Authorized Official - Last Name:BALYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-565-1010
Mailing Address - Street 1:2145 ROSWELL RD
Mailing Address - Street 2:STE 120
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-0821
Mailing Address - Country:US
Mailing Address - Phone:770-565-1010
Mailing Address - Fax:770-565-1037
Practice Address - Street 1:2145 ROSWELL RD
Practice Address - Street 2:STE 120
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0821
Practice Address - Country:US
Practice Address - Phone:770-565-1010
Practice Address - Fax:770-565-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0117331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA350681612AMedicaid