Provider Demographics
NPI:1710008412
Name:VANDERSLICE, KENT D (DC)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:D
Last Name:VANDERSLICE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 EVANS MILL DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-1622
Mailing Address - Country:US
Mailing Address - Phone:770-505-5655
Mailing Address - Fax:770-505-5654
Practice Address - Street 1:110 EVANS MILL DR
Practice Address - Street 2:SUIE 304
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1622
Practice Address - Country:US
Practice Address - Phone:770-505-5655
Practice Address - Fax:770-505-5654
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCFXPMedicare PIN
GAU79598Medicare UPIN