Provider Demographics
NPI:1922150226
Name:CHILDREN'S DENTISTRY OF CAMP CREEK
Entity Type:Organization
Organization Name:CHILDREN'S DENTISTRY OF CAMP CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-344-7900
Mailing Address - Street 1:3890 REDWINE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5509
Mailing Address - Country:US
Mailing Address - Phone:404-344-7900
Mailing Address - Fax:
Practice Address - Street 1:3890 REDWINE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5509
Practice Address - Country:US
Practice Address - Phone:404-344-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty