MEDICARE: IKIDS CHILDRENS DENTISTRY PLLC RANDOLPH WADE HAMILTON III SOLE MBR

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	261QD0000X	Dental Clinic/Center
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1558932780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IKIDS CHILDRENS DENTISTRY PLLC RANDOLPH WADE HAMILTON III SOLE MBR

Provider Business Mailing Address
First Line	:	2970 BRANDYWINE RD STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-5528
Country	:	US
Telephone Number	:	770-692-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	7451 N BEACH ST STE 140
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-5160
Country	:	US
Telephone Number	:	817-295-1144
Fax Number	:

Authorized Official
Title or Position	:	ONBOARDING SPECIALIST
Name	:	MONICA PERKINS
Credential	:
Telephone Number	:	678-244-4844

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	07/08/2021

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