Healthcare Provider Details

I. General information

NPI: 1255464384
Provider Name (Legal Business Name): CUMMING DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BALD RIDGE MARINA RD SUITE 200
CUMMING GA
30041-8494
US

IV. Provider business mailing address

PO BOX 599
CUMMING GA
30028-0599
US

V. Phone/Fax

Practice location:
  • Phone: 770-781-8650
  • Fax: 770-781-2953
Mailing address:
  • Phone: 770-781-8650
  • Fax: 770-781-2953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014775
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015174
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN012306
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011760
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN012514
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015212
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011424
License Number StateGA
# 9
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011242
License Number StateGA

VIII. Authorized Official

Name: DR. KEVIN SHORT
Title or Position: OWNER
Credential: DDS
Phone: 770-781-8650