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General NPI Number Information
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NPI Number | 1366125395
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Entity Type | Organization
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Legal Business Name | PARKSIDE PEDIATRIC AND ORTHODONTIC CARE INC
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Dates
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Enumeration Date | 08/08/2023
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 155 CARNEGIE PL STE 201A
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-3981
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Country | US
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Telephone | 678-228-4266
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Fax | 404-521-4120
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Provider Business Mailing Address
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Address Line | 155 CARNEGIE PL STE 201A
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-3981
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Country | US
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Telephone | 678-228-4266
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Fax | 404-521-4120
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | TARVORIA RUSS
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Credential |
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Telephone | 404-631-7303
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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 |
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License Number State |
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