Provider Demographics
NPI:1255464384
Name:CUMMING DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:CUMMING DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-781-8650
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-0599
Mailing Address - Country:US
Mailing Address - Phone:770-781-8650
Mailing Address - Fax:770-781-2953
Practice Address - Street 1:1200 BALD RIDGE MARINA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8494
Practice Address - Country:US
Practice Address - Phone:770-781-8650
Practice Address - Fax:770-781-2953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014775122300000X
GADN015174122300000X
122300000X
GADN0112421223G0001X
GADN0123061223G0001X
GADN0117601223G0001X
GADN0125141223G0001X
GADN0152121223G0001X
GADN0114241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA825012OtherUNITED CONCORDIA
TN4080537OtherBC BS OF TN