Provider Demographics
NPI:1275660904
Name:J KENNETH WELDON, JR, DMD LLC
Entity Type:Organization
Organization Name:J KENNETH WELDON, JR, DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J. KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-754-1015
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0021
Mailing Address - Country:US
Mailing Address - Phone:706-754-1015
Mailing Address - Fax:
Practice Address - Street 1:172 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-5536
Practice Address - Country:US
Practice Address - Phone:706-754-1015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0113861223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty