Healthcare Provider Details

I. General information

NPI: 1972991248
Provider Name (Legal Business Name): CHILDREN AND TEEN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ELM ST
CUMMING GA
30040-8233
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 770-744-4581
  • Fax:
Mailing address:
  • Phone: 470-207-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number011988
License Number StateGA

VIII. Authorized Official

Name: NICOLE D CARIDE
Title or Position: CREDENTIALING MGR
Credential:
Phone: 727-784-2721