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General NPI Number Information
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NPI Number | 1396108056
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Entity Type | Organization
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Legal Business Name | CENTERS FOR PEDIATRIC DENTAL SEDATION LLC
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Dates
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Enumeration Date | 03/31/2016
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Last Update Date | 03/31/2016
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Provider Practice Location Address
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Address Line | 1631 PHOENIX BLVD STE 8
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City | COLLEGE PARK
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State | GA
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Zip | 30349-5545
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Country | US
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Telephone | 678-545-1682
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Fax | 678-519-0701
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Provider Business Mailing Address
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Address Line | PO BOX 370160
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City | DECATUR
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State | GA
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Zip | 30037-0160
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Country | US
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Telephone | 404-403-4567
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Fax | 678-519-0701
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Authorized Official
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Title or Position | ANESTHESIOLOGIST
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Name | DR. MARCUS QURAN POLK
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Credential | M.D.
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Telephone | 404-403-4567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 040758
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License Number State | GA
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