Provider Demographics
NPI:1649678921
Name:SMDENTALPC
Entity type:Organization
Organization Name:SMDENTALPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MESHKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-688-2223
Mailing Address - Street 1:440 FLAT SHOALS AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1915
Mailing Address - Country:US
Mailing Address - Phone:404-688-2223
Mailing Address - Fax:404-688-6602
Practice Address - Street 1:440 FLAT SHOALS AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1915
Practice Address - Country:US
Practice Address - Phone:404-688-2223
Practice Address - Fax:404-688-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012987302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147751BMedicaid