Provider Demographics
NPI:1164490918
Name:CENTER FOR PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRIC DENTISTRY, LLC
Other - Org Name:CENTER FOR PEDIATRIC DENTISTRY, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-855-8989
Mailing Address - Street 1:1243 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1807
Mailing Address - Country:US
Mailing Address - Phone:706-855-8989
Mailing Address - Fax:706-855-0321
Practice Address - Street 1:1243 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:706-855-8989
Practice Address - Fax:706-855-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA116801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA945328611AMedicaid