Healthcare Provider Details

I. General information

NPI: 1003492224
Provider Name (Legal Business Name): DREAM PEDIATRIC DENTISTRY AND ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2143 NEWNAN CROSSING BLVD E STE 100
NEWNAN GA
30265-2406
US

IV. Provider business mailing address

2143 NEWNAN CROSSING BLVD E STE 100
NEWNAN GA
30265-2406
US

V. Phone/Fax

Practice location:
  • Phone: 470-541-2426
  • Fax:
Mailing address:
  • Phone: 470-541-2426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MALLORY DAWSON
Title or Position: PARTNER
Credential: DMD
Phone: 478-955-6125