Healthcare Provider Details

I. General information

NPI: 1659611184
Provider Name (Legal Business Name): CHRISTINA MCKELLAR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA WIGGINS D.M.D.

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ELM ST STE 301
CUMMING GA
30040-8233
US

IV. Provider business mailing address

101 S PLAYERS CLUB DR APT 20101
TUCSON AZ
85745-5073
US

V. Phone/Fax

Practice location:
  • Phone: 770-744-4581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: