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General NPI Number Information
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NPI Number | 1356749964
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Entity Type | Organization
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Legal Business Name | CHILDRENS DENTAL VILLAGE, LLC
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Dates
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Enumeration Date | 12/12/2014
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Last Update Date | 12/22/2014
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Provider Practice Location Address
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Address Line | 9420 WILLEO RD SUITE 104
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City | ROSWELL
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State | GA
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Zip | 30075-6772
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Country | US
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Telephone | 678-352-8108
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Fax | 678-352-8107
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Provider Business Mailing Address
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Address Line | 9420 WILLEO RD SUITE 104
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City | ROSWELL
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State | GA
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Zip | 30075-6772
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Country | US
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Telephone | 678-352-8108
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Fax | 678-352-8107
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | PRIYA MADHIWALA
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Credential | DMD
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Telephone | 678-352-8108
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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 | DN014199
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License Number State | GA
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