Provider Demographics
NPI:1689938862
Name:TEBO DENTISTRY FOR KIDS DACULA, LLC
Entity Type:Organization
Organization Name:TEBO DENTISTRY FOR KIDS DACULA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-990-6331
Mailing Address - Street 1:PO BOX 1953
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-1953
Mailing Address - Country:US
Mailing Address - Phone:770-925-3300
Mailing Address - Fax:
Practice Address - Street 1:1152 AUBURN RD
Practice Address - Street 2:BUILDING 1, SUITE 101
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5444
Practice Address - Country:US
Practice Address - Phone:770-925-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DN0091131223G0001X
GADN0139191223G0001X
GADN0139971223G0001X
GADN0118631223G0001X
GADN0091131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1033449517OtherNPI
GA1245432004OtherNPI
GA1730316597OtherNPI
124533238OtherNPI