Provider Demographics
NPI:1538641162
Name:MARIETTA SMILE GALLERY
Entity Type:Organization
Organization Name:MARIETTA SMILE GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, FAGD
Authorized Official - Phone:706-466-1796
Mailing Address - Street 1:3535 ROSWELL RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8827
Mailing Address - Country:US
Mailing Address - Phone:770-627-5598
Mailing Address - Fax:
Practice Address - Street 1:3535 ROSWELL RD STE 3
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8827
Practice Address - Country:US
Practice Address - Phone:770-627-5598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014649261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental