Provider Demographics
NPI:1316012636
Name:DR KIM BRADLEY HOOD DMD PC
Entity Type:Organization
Organization Name:DR KIM BRADLEY HOOD DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:HOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PC
Authorized Official - Phone:912-449-6310
Mailing Address - Street 1:643 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516
Mailing Address - Country:US
Mailing Address - Phone:912-449-6310
Mailing Address - Fax:912-449-0009
Practice Address - Street 1:643 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516
Practice Address - Country:US
Practice Address - Phone:912-449-6310
Practice Address - Fax:912-449-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010794122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
839938OtherUNITED CONCORDIA INS