Basic Information
| Provider Information | |||||||||
| NPI: | 1689877557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOOL SMILES PTC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAYFIELD | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 6789045665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN011874 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.