MEDICARE: CHILDREN AND TEEN DENTAL GROUP

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	011988	GA

General Provider Information

NPI Number	:	1972991248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN AND TEEN DENTAL GROUP

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	:	285 ELM ST
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-8233
Country	:	US
Telephone Number	:	770-744-4581
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN SMITH
Credential	:
Telephone Number	:	470-207-3264

Provider Enumeration Date	:	01/08/2015
Last Update Date	:	05/20/2026

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