Healthcare Provider Details

I. General information

NPI: 1447287909
Provider Name (Legal Business Name): CESAR HUMBERTO CARDENAS DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 LOGANVILLE HWY
GRAYSON GA
30017-1621
US

IV. Provider business mailing address

4810 BERKELEY WALK PT
BERKELEY LAKE GA
30096-6193
US

V. Phone/Fax

Practice location:
  • Phone: 678-969-9785
  • Fax:
Mailing address:
  • Phone: 678-969-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013156
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: