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General NPI Number Information
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NPI Number | 1225402373
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Entity Type | Organization
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Legal Business Name | HOMEGROWN PEDIATRIC DENTISTRY AND ORTHODONTICS
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Dates
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Enumeration Date | 11/30/2015
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Last Update Date | 11/30/2015
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Provider Practice Location Address
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Address Line | 405 ARROWHEAD BLVD
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City | JONESBORO
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State | GA
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Zip | 30236-1254
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Country | US
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Telephone | 770-471-1991
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Fax |
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Provider Business Mailing Address
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Address Line | 1005 TIMBER LAKE DR
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City | CUMMING
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State | GA
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Zip | 30041-8606
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Country | US
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Telephone | 386-212-6669
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Fax |
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Authorized Official
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Title or Position | MEMBER/ PEDIATRIC DENTIST
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Name | CHRISTINA MCKELLAR
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Credential |
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Telephone | 386-212-6669
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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 | DN014531
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License Number State | GA
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