MEDICARE: CHILDREN'S DENTISTRY OF CAMP CREEK

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	1223P0221X	Pediatric Dentistry	DN012710	GA

General Provider Information

NPI Number	:	1922150226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTISTRY OF CAMP CREEK

Provider Business Mailing Address
First Line	:	3890 REDWINE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5509
Country	:	US
Telephone Number	:	404-344-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3890 REDWINE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5509
Country	:	US
Telephone Number	:	404-344-7900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEREK D MASON
Credential	:
Telephone Number	:	404-344-7900

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/22/2020

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Directions to “CHILDREN'S DENTISTRY OF CAMP CREEK ” Practice Location

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