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Organization
CHILDRENS DENTISTRY OF LITHONIA LLC
Active
Organization
CHILDRENS DENTISTRY OF LITHONIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ADESEGUN OLUSHOLA TEWOGBADE DMD (OWNER)
(770) 469-4192
Entity
Organization
Contact information
Practice address
374 C NORTH DESHON ROAD, STONE MOUNTAIN, GA 30087
(770) 469-4192
(770) 469-4195
Mailing address
PO BOX 870272, STONE MOUNTAIN, GA 30087-0007
(770) 469-4192
(770) 469-4195
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
DN013400
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1952449944
INDIVIDUAL NPI
—
05
—
853805701A
—
GA
Enumeration date
06/09/2008
Last updated
06/09/2008
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