Provider Demographics
NPI:1780036848
Name:SMILES OF DECATUR P.C.
Entity Type:Organization
Organization Name:SMILES OF DECATUR P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAUZARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-322-0059
Mailing Address - Street 1:2458 WESLEY CHAPEL RD STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-3423
Mailing Address - Country:US
Mailing Address - Phone:770-322-0059
Mailing Address - Fax:
Practice Address - Street 1:2458 WESLEY CHAPEL RD STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3423
Practice Address - Country:US
Practice Address - Phone:770-322-0059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty