Provider Demographics
NPI:1003278904
Name:DENTISTRY AT KENNESAW POINT
Entity Type:Organization
Organization Name:DENTISTRY AT KENNESAW POINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYANDUKHTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KALANTARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-275-2066
Mailing Address - Street 1:1350 WOOTEN LAKE RD NW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1344
Mailing Address - Country:US
Mailing Address - Phone:678-275-2066
Mailing Address - Fax:678-275-2074
Practice Address - Street 1:1350 WOOTEN LAKE RD NW
Practice Address - Street 2:SUITE 203
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1344
Practice Address - Country:US
Practice Address - Phone:678-275-2066
Practice Address - Fax:678-275-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA154041182LMedicaid