Provider Demographics
NPI:1477760510
Name:IT'S A SMALL WORLD CHILDREN'S DENTISTRY
Entity Type:Organization
Organization Name:IT'S A SMALL WORLD CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTAILING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:2680 HIGHWAY 34 EAST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1330
Mailing Address - Country:US
Mailing Address - Phone:770-502-9733
Mailing Address - Fax:770-502-9758
Practice Address - Street 1:2680 HIGHWAY 34 EAST
Practice Address - Street 2:
Practice Address - City:NEWMAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1330
Practice Address - Country:US
Practice Address - Phone:770-502-9733
Practice Address - Fax:770-502-9758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0117411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000753871Medicaid