| Organization Name: | FABULOUS SMILES OF LILBURN |
| NPI Number: | 1205211133 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NIKKI ROLLS (OFFICE MANAGER) |
| Mailing Address: | 331 Arcado Rd Nw Lilburn |
| State: | GA US |
| Postal Code: | 300473077 |
| Phone Number: | 7705570788 |
| Fax Number: | 4044202951 |
| NPI Enumeration Date: | 07/21/2015 |
| NPI Last Update Date: | 07/21/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 305S00000X |
| License Number: | DN011973 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Managed Care Organizations |
| Taxonomy Classification: | Point of Service |
| Taxonomy Specialization: | |
| Taxonomy Definition: | This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO but have the option to go outside the networks for an additional cost. |