Provider Demographics
NPI:1023264322
Name:COSMETIC AND FAMILY DENTISTRY OF MARIETTA
Entity type:Organization
Organization Name:COSMETIC AND FAMILY DENTISTRY OF MARIETTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR./DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-226-0008
Mailing Address - Street 1:PO BOX 7718
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-1718
Mailing Address - Country:US
Mailing Address - Phone:770-226-0008
Mailing Address - Fax:770-226-0700
Practice Address - Street 1:1611 SANDS PL SE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8704
Practice Address - Country:US
Practice Address - Phone:770-226-0008
Practice Address - Fax:770-226-0700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COSMETIC AND FAMILY DENTISTRY OF MARIETTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012484122300000X
GADN012485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA829858019AMedicaid
GA829858019BMedicaid