Provider Demographics
NPI:1811516479
Name:MOUTHPEACE DENTAL 4, LLC
Entity type:Organization
Organization Name:MOUTHPEACE DENTAL 4, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SYRETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-371-1423
Mailing Address - Street 1:2149 BRANNEN RD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-4117
Mailing Address - Country:US
Mailing Address - Phone:312-371-1423
Mailing Address - Fax:
Practice Address - Street 1:541 FOREST PKWY STE 18
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-6110
Practice Address - Country:US
Practice Address - Phone:404-228-6801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental