Provider Demographics
NPI:1841400546
Name:CUMBERBATCH, KHALIL DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHALIL
Middle Name:DANIEL
Last Name:CUMBERBATCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 FLAT SHOALS RD
Mailing Address - Street 2:STE 100
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3660 FLAT SHOALS RD
Practice Address - Street 2:STE 100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1635
Practice Address - Country:US
Practice Address - Phone:404-243-0217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN013502OtherSTATE DENTAL LICENCE