Provider Demographics
NPI:1962660555
Name:FABULOUS SMILES OF ATLANTA LLC
Entity Type:Organization
Organization Name:FABULOUS SMILES OF ATLANTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-758-0770
Mailing Address - Street 1:1188 RALPH DAVID ABERNATHY BLVD SW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1754
Mailing Address - Country:US
Mailing Address - Phone:404-758-0770
Mailing Address - Fax:
Practice Address - Street 1:1188 RALPH DAVID ABERNATHY BLVD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1754
Practice Address - Country:US
Practice Address - Phone:404-758-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011973305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00814965CMedicaid