Provider Demographics
NPI:1396108056
Name:CENTERS FOR PEDIATRIC DENTAL SEDATION LLC
Entity type:Organization
Organization Name:CENTERS FOR PEDIATRIC DENTAL SEDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:QURAN
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-403-4567
Mailing Address - Street 1:PO BOX 370160
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0160
Mailing Address - Country:US
Mailing Address - Phone:404-403-4567
Mailing Address - Fax:678-519-0701
Practice Address - Street 1:1631 PHOENIX BLVD STE 8
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5545
Practice Address - Country:US
Practice Address - Phone:678-545-1682
Practice Address - Fax:678-519-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040758261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental