Healthcare Provider Details

I. General information

NPI: 1023569902
Provider Name (Legal Business Name): CHILDREN AND TEEN DENTAL GROUP OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 E MARSHALL ST STE 100
WEST CHESTER PA
19380-4400
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 610-918-2400
  • Fax:
Mailing address:
  • Phone: 770-744-4581
  • 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: BRIAN SMITH
Title or Position: CFO
Credential:
Phone: 770-231-5348