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
1	122300000X	Dentist
2	1223G0001X	General Practice Dentistry
3	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1568280519
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	:	313 MOOTY BRIDGE RD STE 202
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-1809
Country	:	US
Telephone Number	:	706-837-0123
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BRIAN SMITH
Credential	:
Telephone Number	:	470-750-4866

Provider Enumeration Date	:	09/30/2024
Last Update Date	:	06/26/2026

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