Healthcare Provider Details

I. General information

NPI: 1164490918
Provider Name (Legal Business Name): CENTER FOR PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

IV. Provider business mailing address

1243 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

V. Phone/Fax

Practice location:
  • Phone: 706-855-8989
  • Fax: 706-855-0321
Mailing address:
  • Phone: 706-855-8989
  • Fax: 706-855-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number11680
License Number StateGA

VIII. Authorized Official

Name: MS. MARY SHIRLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 706-855-8989