Healthcare Provider Details

I. General information

NPI: 1598828063
Provider Name (Legal Business Name): RICHARD W. KINSEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6043 PRESTLEY MILL RD SUITE A
DOUGLASVILLE GA
30134-2280
US

IV. Provider business mailing address

6043 PRESTLEY MILL RD SUITE A
DOUGLASVILLE GA
30134-2280
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-3797
  • Fax: 770-949-9077
Mailing address:
  • Phone: 770-949-3797
  • Fax: 770-949-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number009063
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: