Healthcare Provider Details

I. General information

NPI: 1194309930
Provider Name (Legal Business Name): CHILDREN AND TEEN DENTAL GROUP OF FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5245 US HIGHWAY 19
NEW PORT RICHEY FL
34652-3967
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 727-847-3113
  • Fax: 727-847-2904
Mailing address:
  • Phone: 727-784-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JORDAN ROGERS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 470-801-4637