Healthcare Provider Details

I. General information

NPI: 1952764797
Provider Name (Legal Business Name): CHILDREN AND TEEN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 HAMILTON CREEK PKWY SUITE 200
DACULA GA
30019-3293
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 Number
License Number State

VIII. Authorized Official

Name: BRIAN SMITH
Title or Position: CFO
Credential:
Phone: 770-231-5348