Provider Demographics
NPI:1295036028
Name:DENTISTRY FOR CHILDREN OF MCDONOUGH, LLC
Entity Type:Organization
Organization Name:DENTISTRY FOR CHILDREN OF MCDONOUGH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-473-1350
Mailing Address - Street 1:295 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7350
Mailing Address - Country:US
Mailing Address - Phone:770-473-1350
Mailing Address - Fax:770-692-0098
Practice Address - Street 1:1409 HIGHWAY 20 W
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7306
Practice Address - Country:US
Practice Address - Phone:770-692-1000
Practice Address - Fax:770-692-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty