Provider Demographics
NPI:1972678282
Name:HOOD, KIM BRADLEY (DMD PC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:BRADLEY
Last Name:HOOD
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516
Mailing Address - Country:US
Mailing Address - Phone:912-449-6310
Mailing Address - Fax:912-449-0009
Practice Address - Street 1:643 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516
Practice Address - Country:US
Practice Address - Phone:912-449-6310
Practice Address - Fax:912-449-0009
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010794122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00415423AMedicaid
839938OtherUNITED CONCORDIA INS