Provider Demographics
NPI:1376115758
Name:CHILDREN AND TEEN DENTAL GROUP OF FLORIDA
Entity Type:Organization
Organization Name:CHILDREN AND TEEN DENTAL GROUP OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-231-5348
Mailing Address - Street 1:342 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-8376
Mailing Address - Country:US
Mailing Address - Phone:727-784-2721
Mailing Address - Fax:
Practice Address - Street 1:8686 131ST ST STE C
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-2700
Practice Address - Country:US
Practice Address - Phone:727-605-5775
Practice Address - Fax:727-605-5574
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN AND TEEN DENTAL GROUP OF FLORIDA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty