Provider Demographics
NPI:1770754772
Name:PEACHTREE CHILDREN'S DENTISTRY
Entity type:Organization
Organization Name:PEACHTREE CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAMEUN
Authorized Official - Middle Name:NANCY
Authorized Official - Last Name:KIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-497-0110
Mailing Address - Street 1:3820 PLEASANT HILL RD, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:770-497-0110
Mailing Address - Fax:770-497-0580
Practice Address - Street 1:3820 PLEASANT HILL RD, SUITE 1
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-497-0110
Practice Address - Fax:770-497-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO125191223P0221X
GADNO125951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000949616BMedicaid
GA000947944BMedicaid