MEDICARE: CHILDREN AND TEEN DENTAL GROUP OF FLORIDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry
2	1223P0221X	Pediatric Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750056859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN AND TEEN DENTAL GROUP OF FLORIDA

Provider Business Mailing Address
First Line	:	2300 LAKEVIEW PKWY STE 250
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-3954
Country	:	US
Telephone Number	:	470-207-3264
Fax Number	:

Provider Business Practice Location Address
First Line	:	3413 S KINGS AVE STE 200
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-7780
Country	:	US
Telephone Number	:	813-685-0804
Fax Number	:	813-681-7213

Authorized Official
Title or Position	:	CREDENTIALING MGR
Name	:	NICOLE CARIDE
Credential	:
Telephone Number	:	727-784-2721

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	01/21/2025

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Directions to “CHILDREN AND TEEN DENTAL GROUP OF FLORIDA ” Practice Location

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