MEDICARE: CHILDREN AND TEEN DENTAL GROUP OF FLORIDA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry
4	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1396310454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN AND TEEN DENTAL GROUP OF FLORIDA

Provider Business Mailing Address
First Line	:	2300 LAKEVIEW PKWY STE 250
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-3954
Country	:	US
Telephone Number	:	770-744-4522
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 E EDGEWOOD DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-3601
Country	:	US
Telephone Number	:	863-667-6900
Fax Number	:	866-963-6483

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

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/20/2026

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