Provider Demographics
NPI:1972779528
Name:KENNESAW DENTAL ASSOCIATES, P,C.
Entity Type:Organization
Organization Name:KENNESAW DENTAL ASSOCIATES, P,C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-424-8077
Mailing Address - Street 1:3600 CHEROKEE ST NW
Mailing Address - Street 2:SUITE 117
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2027
Mailing Address - Country:US
Mailing Address - Phone:770-424-8077
Mailing Address - Fax:770-499-1929
Practice Address - Street 1:3600 CHEROKEE ST NW
Practice Address - Street 2:SUITE 117
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2027
Practice Address - Country:US
Practice Address - Phone:770-424-8077
Practice Address - Fax:770-499-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010233261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental