Provider Demographics
NPI:1346990108
Name:PEDIATRIC DENTAL SPECIALISTS OF GEORGIA, PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS OF GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-822-6865
Mailing Address - Street 1:315 W PONCE DE LEON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2483
Mailing Address - Country:US
Mailing Address - Phone:404-381-1840
Mailing Address - Fax:404-341-9488
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2483
Practice Address - Country:US
Practice Address - Phone:404-381-1840
Practice Address - Fax:404-341-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty