=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144509852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTISTRY FOR CHILDREN CDCOA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4536 CHAMBLEE DUNWOODY RD SUITE 211
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30338-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-331-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1350 SPRING ST NW STE 600
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-2864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR OF MEDICAID
-----------------------------------------------------
Name | TERESA BLAIR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-331-4014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------