Provider Demographics
NPI:1780884221
Name:KALANTARI, KYANDUKHTA B (DDS)
Entity type:Individual
Prefix:DR
First Name:KYANDUKHTA
Middle Name:B
Last Name:KALANTARI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KYANDUKHTA
Other - Middle Name:B
Other - Last Name:KALANTARI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1350 WOOTEN LAKE RD NW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1344
Mailing Address - Country:US
Mailing Address - Phone:678-275-2066
Mailing Address - Fax:678-275-2074
Practice Address - Street 1:1350 WOOTEN LAKE RD NW
Practice Address - Street 2:SUITE 203
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1344
Practice Address - Country:US
Practice Address - Phone:678-275-2066
Practice Address - Fax:678-275-2074
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA154041182LMedicaid