MEDICARE: WONDERLAND PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry	DN014759	GA

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	:	1871995506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDERLAND PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1570 OLD ALABAMA RD STE 104
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-2108
Country	:	US
Telephone Number	:	678-878-3711
Fax Number	:	678-878-3714

Provider Business Practice Location Address
First Line	:	1570 OLD ALABAMA RD STE 104
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-2108
Country	:	US
Telephone Number	:	678-878-3711
Fax Number	:	678-878-3714

Authorized Official
Title or Position	:	OWNER
Name	:	KARINA BOGDASAROVA
Credential	:	DDS
Telephone Number	:	720-404-8805

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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Directions to “WONDERLAND PEDIATRIC DENTISTRY ” Practice Location

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