1144509852 NPI number — DENTISTRY FOR CHILDREN CDCOA LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144509852 NPI number — DENTISTRY FOR CHILDREN CDCOA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTISTRY FOR CHILDREN CDCOA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144509852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 SPRING ST NW
Provider Second Line Business Mailing Address:
STE 600
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4536 CHAMBLEE DUNWOODY RD
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30338-6200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-331-4104
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BLAIR
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR OF MEDICAID
Authorized Official Telephone Number:
770-331-4014

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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