Provider Demographics
NPI:1750056859
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:CREDENTIALING MGR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-744-4522
Mailing Address - Street 1:342 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-8376
Mailing Address - Country:US
Mailing Address - Phone:770-744-4522
Mailing Address - Fax:
Practice Address - Street 1:107 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5111
Practice Address - Country:US
Practice Address - Phone:813-685-0804
Practice Address - Fax:813-681-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty