Provider Demographics
NPI:1184143059
Name:KENNESAW MOUNTAIN DENTAL ASSOCIATES
Entity type:Organization
Organization Name:KENNESAW MOUNTAIN DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRACTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-425-4100
Mailing Address - Street 1:1815 OLD 41 HWY
Mailing Address - Street 2:STE 310
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152
Mailing Address - Country:US
Mailing Address - Phone:770-425-4100
Mailing Address - Fax:770-425-4111
Practice Address - Street 1:1815 OLD 41 HWY
Practice Address - Street 2:STE 310
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152
Practice Address - Country:US
Practice Address - Phone:770-425-4100
Practice Address - Fax:770-425-4111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNESAW MOUNTAIN DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty