Provider Demographics
NPI:1093019978
Name:KENNESTONE DENTAL DESIGNS, LLC
Entity Type:Organization
Organization Name:KENNESTONE DENTAL DESIGNS, LLC
Other - Org Name:DR. BARRY SMITH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-426-4188
Mailing Address - Street 1:709 CANTON RD NE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8968
Mailing Address - Country:US
Mailing Address - Phone:770-426-4188
Mailing Address - Fax:770-421-8122
Practice Address - Street 1:709 CANTON RD NE
Practice Address - Street 2:SUITE 210
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8968
Practice Address - Country:US
Practice Address - Phone:770-426-4188
Practice Address - Fax:770-421-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0105181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty