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General NPI Number Information
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NPI Number | 1063828499
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Entity Type | Organization
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Legal Business Name | COLUMBUS CHILDREN'S DENTISTRY, PC
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Dates
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Enumeration Date | 07/07/2014
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Last Update Date | 07/07/2014
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Provider Practice Location Address
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Address Line | 4405 N STADIUM DR SUITE B
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City | COLUMBUS
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State | GA
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Zip | 31909-1878
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Country | US
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Telephone | 706-225-0444
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Fax | 706-940-0008
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Provider Business Mailing Address
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Address Line | 4405 N STADIUM DR SUITE B
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City | COLUMBUS
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State | GA
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Zip | 31909-1878
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Country | US
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Telephone | 706-225-0444
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Fax | 706-940-0008
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | MATTHEW LEE KELLER
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Credential | DMD
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Telephone | 706-225-0444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN014428
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License Number State | GA
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