Provider Demographics
NPI:1982930806
Name:FABULOUS SMILES P.C.
Entity Type:Organization
Organization Name:FABULOUS SMILES P.C.
Other - Org Name:FABULOUS SMILES PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALDOUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-767-9356
Mailing Address - Street 1:1188 RALPH DAVID ABERNATHY BLVD SW STE 101
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1754
Mailing Address - Country:US
Mailing Address - Phone:404-767-9356
Mailing Address - Fax:404-529-4465
Practice Address - Street 1:1188 RALPH DAVID ABERNATHY BLVD SW STE 101
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1754
Practice Address - Country:US
Practice Address - Phone:404-767-9356
Practice Address - Fax:404-529-4465
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FABULOUS SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0119471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000809025EMedicaid