Provider Demographics
NPI:1356749964
Name:CHILDRENS DENTAL VILLAGE, LLC
Entity type:Organization
Organization Name:CHILDRENS DENTAL VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADHIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-352-8108
Mailing Address - Street 1:9420 WILLEO RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6772
Mailing Address - Country:US
Mailing Address - Phone:678-352-8108
Mailing Address - Fax:678-352-8107
Practice Address - Street 1:9420 WILLEO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-6772
Practice Address - Country:US
Practice Address - Phone:678-352-8108
Practice Address - Fax:678-352-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1861641698OtherINDIVIDUAL NPI
GA003106680Medicaid