Provider Demographics
NPI:1689877557
Name:KOOL SMILES PTC PC
Entity Type:Organization
Organization Name:KOOL SMILES PTC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-904-5665
Mailing Address - Street 1:400 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5980
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:
Practice Address - Street 1:400 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5980
Practice Address - Country:US
Practice Address - Phone:678-904-5665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty