Provider Demographics
NPI:1518749944
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:CFO
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 1:2300 LAKEVIEW PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3954
Mailing Address - Country:US
Mailing Address - Phone:727-784-2721
Mailing Address - Fax:
Practice Address - Street 1:2939 ALT 19
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1928
Practice Address - Country:US
Practice Address - Phone:727-785-6521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty