Provider Demographics
NPI:1619313384
Name:PEDIATRIC SMILE STUDIO
Entity Type:Organization
Organization Name:PEDIATRIC SMILE STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-982-5130
Mailing Address - Street 1:2526 SHALLOWFORD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3053
Mailing Address - Country:US
Mailing Address - Phone:678-813-0500
Mailing Address - Fax:678-813-0600
Practice Address - Street 1:2526 SHALLOWFORD RD
Practice Address - Street 2:SUITE C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3053
Practice Address - Country:US
Practice Address - Phone:678-813-0500
Practice Address - Fax:678-813-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0142321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108300Medicaid