Provider Demographics
NPI:1699914721
Name:FAMILY SMILES DENTAL
Entity type:Organization
Organization Name:FAMILY SMILES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-505-4746
Mailing Address - Street 1:59 HILLSIDE TRCE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-9476
Mailing Address - Country:US
Mailing Address - Phone:770-505-4746
Mailing Address - Fax:770-505-0047
Practice Address - Street 1:59 HILLSIDE TRCE
Practice Address - Street 2:SUITE 105
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-9476
Practice Address - Country:US
Practice Address - Phone:770-505-4746
Practice Address - Fax:770-505-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA643671594BMedicaid