Provider Demographics
NPI:1629584586
Name:HERRIN CPDS PC
Entity Type:Organization
Organization Name:HERRIN CPDS PC
Other - Org Name:CENTERS FOR PEDIATRIC DENTAL SEDATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:QURAN
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-403-4567
Mailing Address - Street 1:PO BOX 370160
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0160
Mailing Address - Country:US
Mailing Address - Phone:404-403-4567
Mailing Address - Fax:404-521-4044
Practice Address - Street 1:1571 PHOENIX BLVD STE 8
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5536
Practice Address - Country:US
Practice Address - Phone:844-682-4737
Practice Address - Fax:404-521-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141851223P0221X
GADN0130211223P0221X
GADN0148981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003198439AMedicaid