Provider Demographics
NPI:1013117878
Name:CHILDREN'S DENTAL CTR AT BROOKSTONE
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL CTR AT BROOKSTONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:SHEALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-9375
Mailing Address - Street 1:1825 MARS HILL RD NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:770-422-9375
Mailing Address - Fax:770-528-5976
Practice Address - Street 1:1825 MARS HILL RD NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:770-422-9375
Practice Address - Fax:770-528-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty