Provider Demographics
NPI:1457863961
Name:SMILE LEAGUE P.C.
Entity Type:Organization
Organization Name:SMILE LEAGUE P.C.
Other - Org Name:20/32 FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-380-8828
Mailing Address - Street 1:175 BERACAH WALK SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8514
Mailing Address - Country:US
Mailing Address - Phone:202-380-8828
Mailing Address - Fax:
Practice Address - Street 1:80 PEYTON RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1710
Practice Address - Country:US
Practice Address - Phone:678-732-0411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental