Provider Demographics
NPI:1942573662
Name:SOUTHERN SMILES LLC
Entity Type:Organization
Organization Name:SOUTHERN SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-994-6473
Mailing Address - Street 1:275 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-9556
Mailing Address - Country:US
Mailing Address - Phone:478-994-6473
Mailing Address - Fax:
Practice Address - Street 1:275 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-9556
Practice Address - Country:US
Practice Address - Phone:478-994-6473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0118651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty