MEDICARE: PEDIATRIC DENTISTRY FOR INFANTS CHILDREN & TEENS PC

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

General Provider Information

NPI Number	:	1891758991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY FOR INFANTS CHILDREN & TEENS PC

Provider Business Mailing Address
First Line	:	7215 STONECREST PARKWAY
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038
Country	:	US
Telephone Number	:	770-482-4661
Fax Number	:

Provider Business Practice Location Address
First Line	:	7215 STONECREST PARKWAY
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038
Country	:	US
Telephone Number	:	770-482-4661
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WAYNE R MILLER
Credential	:	DMD
Telephone Number	:	770-482-4661

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/10/2008

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