Organization
MINI SMILES PEDIATRIC DENTISTRY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEYSRA M WASHINGTON DDS (OWNER/DENTIST)
(770) 761-5690
Entity
Organization
Contact information
Practice address
1400 DOGWOOD DR SE, CONYERS, GA 30013-5037
(770) 761-5690
(770) 761-9750
Mailing address
1400 DOGWOOD DR SE, CONYERS, GA 30013-5037
(770) 761-5690
(770) 761-9750
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
DN013140
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1376603308
INDIVIDUAL NPI NUMBER
TX
Enumeration date
09/10/2013
Last updated
02/07/2014
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