Provider Demographics
NPI:1073975868
Name:KID'S ZONE DENTISTRY, LLC
Entity Type:Organization
Organization Name:KID'S ZONE DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-882-0591
Mailing Address - Street 1:307 CHURCH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2700
Mailing Address - Country:US
Mailing Address - Phone:706-882-0591
Mailing Address - Fax:706-845-9546
Practice Address - Street 1:307 CHURCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2700
Practice Address - Country:US
Practice Address - Phone:706-882-0591
Practice Address - Fax:706-845-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008745122300000X
GADN014796122300000X
GA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000136848DMedicaid
GA003148248AMedicaid
GA191678896BMedicaid