Provider Demographics
NPI:1205401304
Name:CHILDREN AND TEEN DENTAL GROUP OF ALABAMA
Entity type:Organization
Organization Name:CHILDREN AND TEEN DENTAL GROUP OF ALABAMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-231-5348
Mailing Address - Street 1:2300 LAKEVIEW PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3954
Mailing Address - Country:US
Mailing Address - Phone:727-784-2721
Mailing Address - Fax:
Practice Address - Street 1:4901 DEERFOOT PKWY STE 101
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2697
Practice Address - Country:US
Practice Address - Phone:205-655-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN AND TEEN DENTAL GROUP OF ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty