Provider Demographics
NPI:1750434643
Name:PEACHTREE CHILDREN'S DENTISTRY SNELLVILLE
Entity type:Organization
Organization Name:PEACHTREE CHILDREN'S DENTISTRY SNELLVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:770-979-6400
Mailing Address - Street 1:1905 SCENIC HWY N STE 510
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5635
Mailing Address - Country:US
Mailing Address - Phone:770-979-6400
Mailing Address - Fax:770-979-7465
Practice Address - Street 1:1905 SCENIC HWY N STE 510
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5635
Practice Address - Country:US
Practice Address - Phone:770-979-6400
Practice Address - Fax:770-979-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000949616CMedicaid
GA000947944CMedicaid