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NPI Code Detail

MEDICARE: CENTER FOR PEDIATRIC DENTISTRY, LLC

MEDICARE: CENTER FOR PEDIATRIC DENTISTRY, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223P0221XPediatric Dentistry11680GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1164490918
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTER FOR PEDIATRIC DENTISTRY, LLC
Provider Business Mailing Address
First Line : 1243 AUGUSTA WEST PKWY
Second Line :
City : AUGUSTA
State : GA
Zip : 30909-1807
Country : US
Telephone Number : 706-855-8989
Fax Number : 706-855-0321
Provider Business Practice Location Address
First Line : 1243 AUGUSTA WEST PKWY
Second Line :
City : AUGUSTA
State : GA
Zip : 30909-1807
Country : US
Telephone Number : 706-855-8989
Fax Number : 706-855-0321
Authorized Official
Title or Position : ADMINISTRATOR
Name : MS. MARY SHIRLEY
Credential :
Telephone Number : 706-855-8989
Provider Enumeration Date : 03/09/2006
Last Update Date : 01/18/2021

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Directions to “CENTER FOR PEDIATRIC DENTISTRY, LLC ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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