Healthcare Provider Details

I. General information

NPI: 1437607314
Provider Name (Legal Business Name): CHILDREN AND TEEN DENTAL GROUP OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 DOWLIN FORGE RD
EXTON PA
19341-1550
US

IV. Provider business mailing address

342 N MAIN ST STE 200
ALPHARETTA GA
30009-8376
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-2100
  • Fax:
Mailing address:
  • Phone: 770-744-4522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRIAN SMITH
Title or Position: CFO
Credential:
Phone: 770-231-5348