Healthcare Provider Details

I. General information

NPI: 1669805503
Provider Name (Legal Business Name): KIDS ZONE DENTISTRY & LAGRANGE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHURCH ST STE A
LAGRANGE GA
30240-2700
US

IV. Provider business mailing address

307 CHURCH ST STE 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 TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN009828
License Number StateGA

VIII. Authorized Official

Name: DR. CHUCK PITTS
Title or Position: OWNER
Credential: D.M.D
Phone: 706-882-0591