Provider Demographics
NPI:1558797761
Name:ONE SMILE AWAY INC
Entity Type:Organization
Organization Name:ONE SMILE AWAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYJUAN
Authorized Official - Middle Name:MARCQUELL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-231-0170
Mailing Address - Street 1:4045 JIMMIE DYESS PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9491
Mailing Address - Country:US
Mailing Address - Phone:706-231-0170
Mailing Address - Fax:
Practice Address - Street 1:4159 ELDERS DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9145
Practice Address - Country:US
Practice Address - Phone:706-231-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN017325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107901AMedicaid