Provider Demographics
NPI:1851439459
Name:THE CHILDREN'S DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:THE CHILDREN'S DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROSE-MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-941-8802
Mailing Address - Street 1:560 THORNTON RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1655
Mailing Address - Country:US
Mailing Address - Phone:770-234-4859
Mailing Address - Fax:
Practice Address - Street 1:560 THORNTON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1655
Practice Address - Country:US
Practice Address - Phone:770-234-4859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty