Healthcare Provider Details

I. General information

NPI: 1861308140
Provider Name (Legal Business Name): CHILDREN'S DENTISTRY OF DECATUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5243 SNAPFINGER WOODS DR STE 107
DECATUR GA
30035-4000
US

IV. Provider business mailing address

5243 SNAPFINGER WOODS DR STE 107
DECATUR GA
30035-4000
US

V. Phone/Fax

Practice location:
  • Phone: 770-781-0203
  • Fax: 770-781-0204
Mailing address:
  • Phone: 770-781-0203
  • Fax: 770-781-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARY HANIF
Title or Position: MANAGER
Credential:
Phone: 678-984-5566