=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306426036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN AND TEEN DENTAL GROUP OF ALABAMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2021
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 GEORGE WALLACE DR
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35903-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-546-4604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 LAKEVIEW PKWY STE 250
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-3954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-207-3264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | BRIAN SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-231-5348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------