Healthcare Provider Details

I. General information

NPI: 1437066982
Provider Name (Legal Business Name): CHILDREN'S DENTISTRY OF WEST GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CALUMET CENTER RD
LAGRANGE GA
30241-6712
US

IV. Provider business mailing address

202 CALUMET CENTER RD
LAGRANGE GA
30241-6712
US

V. Phone/Fax

Practice location:
  • Phone: 706-298-5007
  • Fax:
Mailing address:
  • Phone: 706-298-5007
  • Fax: 706-298-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANGELA DENISE BULLOCH-PATTERSON
Title or Position: OWNER
Credential: DMD
Phone: 706-298-5007