Provider Demographics
NPI:1184059073
Name:MINI SMILES PEDIATRIC DENTISTRY, PC
Entity type:Organization
Organization Name:MINI SMILES PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEYSRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-761-5690
Mailing Address - Street 1:1400 DOGWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5037
Mailing Address - Country:US
Mailing Address - Phone:770-761-5690
Mailing Address - Fax:770-761-9750
Practice Address - Street 1:1400 DOGWOOD DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5037
Practice Address - Country:US
Practice Address - Phone:770-761-5690
Practice Address - Fax:770-761-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1376603308OtherINDIVIDUAL NPI NUMBER