Provider Demographics
NPI:1821771072
Name:PROUD SMILES LLC
Entity Type:Organization
Organization Name:PROUD SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RADHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-257-0091
Mailing Address - Street 1:5290 ROSWELL RD STE A130
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1978
Mailing Address - Country:US
Mailing Address - Phone:404-257-0091
Mailing Address - Fax:
Practice Address - Street 1:5290 ROSWELL RD STE A130
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1978
Practice Address - Country:US
Practice Address - Phone:404-257-0091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty