Provider Demographics
NPI:1023569902
Name:CHILDREN AND TEEN DENTAL GROUP OF PENNSYLVANIA
Entity Type:Organization
Organization Name:CHILDREN AND TEEN DENTAL GROUP OF PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-231-5348
Mailing Address - Street 1:342 N MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-8376
Mailing Address - Country:US
Mailing Address - Phone:770-744-4581
Mailing Address - Fax:
Practice Address - Street 1:795 E MARSHALL ST
Practice Address - Street 2:STE 100
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4400
Practice Address - Country:US
Practice Address - Phone:610-918-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty