Provider Demographics
NPI:1225402373
Name:HOMEGROWN PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:HOMEGROWN PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/ PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-212-6669
Mailing Address - Street 1:1005 TIMBER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8606
Mailing Address - Country:US
Mailing Address - Phone:386-212-6669
Mailing Address - Fax:
Practice Address - Street 1:405 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1254
Practice Address - Country:US
Practice Address - Phone:770-471-1991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0145311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty