MEDICARE: CHILDREN AND TEEN DENTAL GROUP

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
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1184584666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN AND TEEN DENTAL GROUP

Provider Business Mailing Address
First Line	:	2300 LAKEVIEW PKWY STE 250
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-3954
Country	:	US
Telephone Number	:	470-207-3264
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 LILBURN STONE MOUNTAIN RD STE A
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-2873
Country	:	US
Telephone Number	:	770-923-5500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN SMITH
Credential	:
Telephone Number	:	470-207-3264

Provider Enumeration Date	:	11/17/2025
Last Update Date	:	05/20/2026

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