Healthcare Provider Details

I. General information

NPI: 1073975868
Provider Name (Legal Business Name): KID'S ZONE DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHURCH ST SUITE A
LAGRANGE GA
30240-2700
US

IV. Provider business mailing address

307 CHURCH ST SUITE A
LAGRANGE GA
30240-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-0591
  • Fax: 706-845-9546
Mailing address:
  • Phone: 706-882-0591
  • Fax: 706-845-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN008745
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014796
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. LAURA L WEBB
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-882-0591