Provider Demographics
NPI:1801916812
Name:SMYLY, DAN MARTIN (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:MARTIN
Last Name:SMYLY
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1417
Mailing Address - Country:US
Mailing Address - Phone:404-296-2307
Mailing Address - Fax:404-296-0850
Practice Address - Street 1:4765 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1417
Practice Address - Country:US
Practice Address - Phone:404-296-2307
Practice Address - Fax:404-296-0850
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA983156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-3362953OtherEIN #