Provider Demographics
NPI:1568280519
Name:CHILDREN AND TEEN DENTAL GROUP
Entity type:Organization
Organization Name:CHILDREN AND TEEN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-784-2721
Mailing Address - Street 1:2300 LAKEVIEW PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3954
Mailing Address - Country:US
Mailing Address - Phone:470-207-3264
Mailing Address - Fax:
Practice Address - Street 1:313 MOOTY BRIDGE RD STE 202
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-1809
Practice Address - Country:US
Practice Address - Phone:706-837-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN AND TEEN DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty