Provider Demographics
NPI:1861403552
Name:INNOVATIVE SMILES AT THE FORUM PC
Entity type:Organization
Organization Name:INNOVATIVE SMILES AT THE FORUM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:K
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-368-1110
Mailing Address - Street 1:5185 PEACHTREE PKWY
Mailing Address - Street 2:BLDG 1200 STE 201
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092
Mailing Address - Country:US
Mailing Address - Phone:770-368-1110
Mailing Address - Fax:770-368-1114
Practice Address - Street 1:5185 PEACHTREE PKWY
Practice Address - Street 2:BLDG 1200 STE 201
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:770-368-1110
Practice Address - Fax:770-368-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty