Provider Demographics
NPI:1952185399
Name:BROWN, KOFI DEMETRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:KOFI
Middle Name:DEMETRICK
Last Name:BROWN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 LACOSTA DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9483
Mailing Address - Country:US
Mailing Address - Phone:229-376-9234
Mailing Address - Fax:
Practice Address - Street 1:4365 ROSWELL RD NE STE 4411
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3315
Practice Address - Country:US
Practice Address - Phone:470-239-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1231681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice