Provider Demographics
NPI:1891758991
Name:PEDIATRIC DENTISTRY FOR INFANTS CHILDREN & TEENS PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY FOR INFANTS CHILDREN & TEENS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-482-4661
Mailing Address - Street 1:7215 STONECREST PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038
Mailing Address - Country:US
Mailing Address - Phone:770-482-4661
Mailing Address - Fax:
Practice Address - Street 1:7215 STONECREST PARKWAY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038
Practice Address - Country:US
Practice Address - Phone:770-482-4661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty