Provider Demographics
NPI:1730348210
Name:CHILDRENS DENTISTRY OF LITHONIA LLC
Entity type:Organization
Organization Name:CHILDRENS DENTISTRY OF LITHONIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADESEGUN
Authorized Official - Middle Name:OLUSHOLA
Authorized Official - Last Name:TEWOGBADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-469-4192
Mailing Address - Street 1:PO BOX 870272
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0007
Mailing Address - Country:US
Mailing Address - Phone:770-469-4192
Mailing Address - Fax:770-469-4195
Practice Address - Street 1:374 C NORTH DESHON ROAD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087
Practice Address - Country:US
Practice Address - Phone:770-469-4192
Practice Address - Fax:770-469-4195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013400261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952449944OtherINDIVIDUAL NPI
GA853805701AMedicaid