Provider Demographics
NPI:1548584154
Name:SMOKE RISE DENTAL
Entity Type:Organization
Organization Name:SMOKE RISE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABDEL- MOETI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-923-5500
Mailing Address - Street 1:5500 LILBURN STONE MOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2873
Mailing Address - Country:US
Mailing Address - Phone:770-923-5500
Mailing Address - Fax:770-923-0044
Practice Address - Street 1:5500 LILBURN STONE MOUNTAIN RD STE A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-2873
Practice Address - Country:US
Practice Address - Phone:770-923-5500
Practice Address - Fax:770-923-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN 013813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty