Provider Demographics
NPI:1063477115
Name:KISSING, DOMINIK (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIK
Middle Name:
Last Name:KISSING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5780 PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-7927
Mailing Address - Country:US
Mailing Address - Phone:678-891-6541
Mailing Address - Fax:
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-224-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64125207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112332DMedicaid