Healthcare Provider Details

I. General information

NPI: 1891758991
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY FOR INFANTS CHILDREN & TEENS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7215 STONECREST PARKWAY
LITHONIA GA
30038
US

IV. Provider business mailing address

7215 STONECREST PARKWAY
LITHONIA GA
30038
US

V. Phone/Fax

Practice location:
  • Phone: 770-482-4661
  • Fax:
Mailing address:
  • Phone: 770-482-4661
  • 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: WAYNE R MILLER
Title or Position: OWNER
Credential: DMD
Phone: 770-482-4661