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General NPI Number Information
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NPI Number | 1871995506
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Entity Type | Organization
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Legal Business Name | WONDERLAND PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 09/25/2014
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Last Update Date | 09/25/2014
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Provider Practice Location Address
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Address Line | 1570 OLD ALABAMA RD STE 104
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City | ROSWELL
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State | GA
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Zip | 30076-2108
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Country | US
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Telephone | 678-878-3711
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Fax | 678-878-3714
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Provider Business Mailing Address
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Address Line | 1570 OLD ALABAMA RD STE 104
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City | ROSWELL
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State | GA
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Zip | 30076-2108
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Country | US
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Telephone | 678-878-3711
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Fax | 678-878-3714
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Authorized Official
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Title or Position | OWNER
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Name | KARINA BOGDASAROVA
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Credential | DDS
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Telephone | 720-404-8805
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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 | DN014759
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License Number State | GA
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