Provider Demographics
NPI:1356016059
Name:KDENTISTRY26 LLC
Entity Type:Organization
Organization Name:KDENTISTRY26 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNG DO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-641-5993
Mailing Address - Street 1:403 N GILMER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863-2053
Mailing Address - Country:US
Mailing Address - Phone:334-623-0180
Mailing Address - Fax:334-623-0190
Practice Address - Street 1:403 N GILMER AVE STE B
Practice Address - Street 2:
Practice Address - City:LANETT
Practice Address - State:AL
Practice Address - Zip Code:36863-2053
Practice Address - Country:US
Practice Address - Phone:334-623-0180
Practice Address - Fax:334-623-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841892247OtherINDIVIDUAL NPI