Provider Demographics
NPI:1740984574
Name:GREAT SMILES BUFORD CENTER LLC
Entity type:Organization
Organization Name:GREAT SMILES BUFORD CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIDOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-828-9005
Mailing Address - Street 1:2055 BARRETT LAKES BLVD # 822
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-8003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1879 BUFORD HWY STE 5A
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3628
Practice Address - Country:US
Practice Address - Phone:470-722-5591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty