Healthcare Provider Details

I. General information

NPI: 1972010502
Provider Name (Legal Business Name): CUMMING PEDIATRIC DENTISTRY & ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3275 MARKET PLACE BLVD STE 150
CUMMING GA
30041-7980
US

IV. Provider business mailing address

3275 MARKET PLACE BLVD STE 150
CUMMING GA
30041-7980
US

V. Phone/Fax

Practice location:
  • Phone: 770-781-8650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number015146
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number011424
License Number StateGA

VIII. Authorized Official

Name: LINDA MONELL
Title or Position: BUSINESS MANAGER
Credential:
Phone: 770-781-8650