Healthcare Provider Details

I. General information

NPI: 1427428085
Provider Name (Legal Business Name): CHILDREN'S DENTAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RIVERBEND DR SW STE 130
ROME GA
30161-6005
US

IV. Provider business mailing address

15 RIVERBEND DR SW STE 130
ROME GA
30161-6005
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-1283
  • Fax: 770-672-7480
Mailing address:
  • Phone: 706-232-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER A CLINE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 706-232-1283