MEDICARE: DENTISTRY FOR CHILDREN OF CARTERSVILLE 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
1	1223G0001X	General Practice Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1215205661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRY FOR CHILDREN OF CARTERSVILLE LLC

Provider Business Mailing Address
First Line	:	1350 SPRING ST NW
Second Line	:	SIXTH FLOOR
City	:	ATLANTA
State	:	GA
Zip	:	30309-2864
Country	:	US
Telephone Number	:	404-389-1950
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 BOWEN CT
Second Line	:
City	:	CARTERSVILLE
State	:	GA
Zip	:	30120-2493
Country	:	US
Telephone Number	:	404-389-1950
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES COULTER
Credential	:	DDS
Telephone Number	:	404-389-1950

Provider Enumeration Date	:	12/13/2011
Last Update Date	:	12/13/2011

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