Provider Demographics
NPI:1720395924
Name:SOUTHERN SMILES FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:SOUTHERN SMILES FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GENISE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-622-0622
Mailing Address - Street 1:475 BILL KENNEDY WAY SE
Mailing Address - Street 2:SUITE D & E
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-6847
Mailing Address - Country:US
Mailing Address - Phone:404-622-0622
Mailing Address - Fax:404-622-0624
Practice Address - Street 1:475 BILL KENNEDY WAY SE
Practice Address - Street 2:SUITE D & E
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-6847
Practice Address - Country:US
Practice Address - Phone:404-622-0622
Practice Address - Fax:404-622-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1548362718OtherINDIVIDUAL NPI #
GA000957712KMedicaid