Provider Demographics
NPI:1457570863
Name:PEABODY, GADIA KUMUNJUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GADIA
Middle Name:KUMUNJUN
Last Name:PEABODY
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 1:2201 S GETTY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1207
Mailing Address - Country:US
Mailing Address - Phone:231-767-9830
Mailing Address - Fax:231-737-1808
Practice Address - Street 1:2201 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-767-9830
Practice Address - Fax:231-737-1808
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA639071223P0700X
IL0190261301223G0001X
MI29010115071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice