Provider Demographics
NPI:1376797829
Name:COVENANT CHILDRENS DENTAL CARE CENTER
Entity Type:Organization
Organization Name:COVENANT CHILDRENS DENTAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-323-1280
Mailing Address - Street 1:7446 COVINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7612
Mailing Address - Country:US
Mailing Address - Phone:770-323-1280
Mailing Address - Fax:770-323-8622
Practice Address - Street 1:7446 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7612
Practice Address - Country:US
Practice Address - Phone:770-323-1280
Practice Address - Fax:770-323-8622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0113701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty