Provider Demographics
NPI:1972991248
Name:CHILDREN AND TEEN DENTAL GROUP, PC
Entity Type:Organization
Organization Name:CHILDREN AND TEEN DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:HISER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:770-744-4581
Mailing Address - Street 1:285 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8233
Mailing Address - Country:US
Mailing Address - Phone:770-744-4581
Mailing Address - Fax:
Practice Address - Street 1:285 ELM ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8233
Practice Address - Country:US
Practice Address - Phone:770-744-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0119881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty