Healthcare Provider Details

I. General information

NPI: 1427801091
Provider Name (Legal Business Name): FORSYTHPEDIATRICDENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 WINDERMERE PKWY STE 501
CUMMING GA
30041-7015
US

IV. Provider business mailing address

3810 WINDERMERE PKWY STE 501
CUMMING GA
30041-7015
US

V. Phone/Fax

Practice location:
  • Phone: 770-889-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NICK KIM
Title or Position: OWNER
Credential: DMD
Phone: 334-549-2714