Provider Demographics
NPI:1518622869
Name:SMILE SOURCE ATLANTA EAST
Entity Type:Organization
Organization Name:SMILE SOURCE ATLANTA EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEONKA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-897-1699
Mailing Address - Street 1:1100 PEACHTREE ST NE STE 680
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4516
Mailing Address - Country:US
Mailing Address - Phone:404-897-1699
Mailing Address - Fax:404-897-1599
Practice Address - Street 1:1147 S HAIRSTON RD STE A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2757
Practice Address - Country:US
Practice Address - Phone:678-515-4200
Practice Address - Fax:678-515-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN122249OtherGA BOARD OF DENTITSTRY
GADN011069OtherGA BOARD OF DENTISTRY