Provider Demographics
NPI:1053034785
Name:PEDIATRIC SEDATION CENTER OF GA
Entity type:Organization
Organization Name:PEDIATRIC SEDATION CENTER OF GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SERENTHES
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-599-2333
Mailing Address - Street 1:8180 MALL PKWY STE 810
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6911
Mailing Address - Country:US
Mailing Address - Phone:470-395-2518
Mailing Address - Fax:470-243-7395
Practice Address - Street 1:8180 MALL PKWY STE 810
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6911
Practice Address - Country:US
Practice Address - Phone:470-395-2518
Practice Address - Fax:470-243-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-19
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty