Healthcare Provider Details

I. General information

NPI: 1619214343
Provider Name (Legal Business Name): KALOS SURGICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5670 PEACHTREE DUNWOODY RD NE STE 910
ATLANTA GA
30342-1699
US

IV. Provider business mailing address

5670 PEACHTREE DUNWOODY RD NE STE 910
ATLANTA GA
30342-1699
US

V. Phone/Fax

Practice location:
  • Phone: 404-963-6665
  • Fax:
Mailing address:
  • Phone: 404-963-6665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number54676
License Number StateGA

VIII. Authorized Official

Name: DR. BENJAMIN COLLIN STONG
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 404-963-6665