Provider Demographics
NPI:1063828499
Name:COLUMBUS CHILDREN'S DENTISTRY, PC
Entity Type:Organization
Organization Name:COLUMBUS CHILDREN'S DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-225-0444
Mailing Address - Street 1:4405 N STADIUM DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1878
Mailing Address - Country:US
Mailing Address - Phone:706-225-0444
Mailing Address - Fax:706-940-0008
Practice Address - Street 1:4405 N STADIUM DR
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1878
Practice Address - Country:US
Practice Address - Phone:706-225-0444
Practice Address - Fax:706-940-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0144281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145601AMedicaid