Provider Demographics
NPI:1871995506
Name:WONDERLAND PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:WONDERLAND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGDASAROVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-404-8805
Mailing Address - Street 1:1570 OLD ALABAMA RD STE 104
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2108
Mailing Address - Country:US
Mailing Address - Phone:678-878-3711
Mailing Address - Fax:678-878-3714
Practice Address - Street 1:1570 OLD ALABAMA RD STE 104
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2108
Practice Address - Country:US
Practice Address - Phone:678-878-3711
Practice Address - Fax:678-878-3714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0147591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146415Medicaid