Healthcare Provider Details

I. General information

NPI: 1609632082
Provider Name (Legal Business Name): CHILDREN AND TEEN ORTHO GROUP OF FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 S FLORIDA AVE
LAKELAND FL
33813-1109
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 863-333-0397
  • Fax:
Mailing address:
  • Phone: 470-207-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRIAN SMITH
Title or Position: CHIEF OFFICER
Credential:
Phone: 770-231-5348