Provider Demographics
NPI:1427428085
Name:CHILDREN'S DENTAL CENTER, PC
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CENTER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-232-1283
Mailing Address - Street 1:15 RIVERBEND DR SW
Mailing Address - Street 2:STE 130
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6005
Mailing Address - Country:US
Mailing Address - Phone:706-232-1283
Mailing Address - Fax:
Practice Address - Street 1:15 RIVERBEND DR SW
Practice Address - Street 2:STE 130
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6005
Practice Address - Country:US
Practice Address - Phone:706-232-1283
Practice Address - Fax:770-672-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty