Provider Demographics
NPI:1881859163
Name:KIDZ KORNER DENTISTRY LLC
Entity Type:Organization
Organization Name:KIDZ KORNER DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-238-1264
Mailing Address - Street 1:143 CANAL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-6007
Mailing Address - Country:US
Mailing Address - Phone:912-856-1486
Mailing Address - Fax:
Practice Address - Street 1:143 CANAL ST STE 400
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6007
Practice Address - Country:US
Practice Address - Phone:912-856-1486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty