Provider Demographics
NPI:1942293576
Name:SOUTHERN SMILES DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SOUTHERN SMILES DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-968-1720
Mailing Address - Street 1:6612 EXCHANGE PL
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2358
Mailing Address - Country:US
Mailing Address - Phone:770-968-1720
Mailing Address - Fax:770-968-1625
Practice Address - Street 1:6612 EXCHANGE PL
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2358
Practice Address - Country:US
Practice Address - Phone:770-968-1720
Practice Address - Fax:770-968-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty