Provider Demographics
NPI:1972263119
Name:SMILE 23 GEORGIA LLC
Entity Type:Organization
Organization Name:SMILE 23 GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CDO
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:TUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-233-1882
Mailing Address - Street 1:2265 CASCADE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-2861
Mailing Address - Country:US
Mailing Address - Phone:404-755-8539
Mailing Address - Fax:
Practice Address - Street 1:2265 CASCADE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-2861
Practice Address - Country:US
Practice Address - Phone:404-755-8539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty