NPIMap

Organization Active NPI

Center for Pediatric Dentistry, LLC

  • Pediatric Dentistry
  • Augusta, GA
National Provider Identifier
1164490918
Registry record updated Jan 18, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
11680 Issued in GA
Legal business name
CENTER FOR PEDIATRIC DENTISTRY, LLC
Practice address
1243 Augusta West Pkwy
Augusta, GA 30909-1807
Phone
(706) 855-8989
Fax
(706) 855-0321
NPI assigned
Mar 9, 2006
Last updated
Jan 18, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 18, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Mary Shirley
Title
Administrator
Phone
(706) 855-8989

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Dentistry 1223P0221X 11680 GA Primary

Addresses

Primary practice location

1243 Augusta West Pkwy
Augusta, GA 30909-1807

Mailing address

1243 Augusta West Pkwy
Augusta, GA 30909-1807
Phone (706) 855-8989

Other identifiers 1

IdentifierTypeStateIssuer
945328611AMedicaidGA

Other names 1

  • Center For Pediatric Dentistry, PC Former legal business name

National Provider Directory

National Provider Directory

Locations

1243 Augusta West Pkwy
Augusta, GA 30909
Phone (706) 303-0060

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1610928000000",
    "number": "1164490918",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1243 AUGUSTA WEST PKWY",
            "city": "AUGUSTA",
            "state": "GA",
            "postal_code": "309091807",
            "telephone_number": "706-855-8989",
            "fax_number": "706-855-0321"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1243 AUGUSTA WEST PKWY",
            "city": "AUGUSTA",
            "state": "GA",
            "postal_code": "309091807",
            "telephone_number": "706-855-8989",
            "fax_number": "706-855-0321"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTER FOR PEDIATRIC DENTISTRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-09",
        "last_updated": "2021-01-18",
        "certification_date": "2021-01-18",
        "status": "A",
        "authorized_official_last_name": "SHIRLEY",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "706-855-8989",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "GA",
            "license": "11680",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "945328611A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Center For Pediatric Dentistry, PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Augusta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.