Provider Demographics
NPI:1972973766
Name:BEAUTIFUL SMILES OF FAYETTEVILLE
Entity Type:Organization
Organization Name:BEAUTIFUL SMILES OF FAYETTEVILLE
Other - Org Name:TRINITY PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-696-6595
Mailing Address - Street 1:719 W. LANIER AVENUE SUITE A1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 LANIER AVE W STE A1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7634
Practice Address - Country:US
Practice Address - Phone:404-696-6595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty