Provider Demographics
NPI:1508549932
Name:SPARKLING SMILES FAYETTEVILLE LLC
Entity Type:Organization
Organization Name:SPARKLING SMILES FAYETTEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-424-2990
Mailing Address - Street 1:1233 HIGHWAY 54 W STE 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4542
Mailing Address - Country:US
Mailing Address - Phone:770-461-6465
Mailing Address - Fax:
Practice Address - Street 1:1233 HIGHWAY 54 W STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4542
Practice Address - Country:US
Practice Address - Phone:770-461-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty