Provider Demographics
NPI:1477200137
Name:KENNESAW MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:KENNESAW MODERN DENTISTRY, PC
Other - Org Name:KENNESAW MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-832-0527
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:1125 ERNEST W BARRETT PKWY NW BLDG 200
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4535
Practice Address - Country:US
Practice Address - Phone:678-832-0527
Practice Address - Fax:678-835-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty