Healthcare Provider Details

I. General information

NPI: 1164675203
Provider Name (Legal Business Name): PK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 TERRELL MILL RD
MARIETTA GA
30067
US

IV. Provider business mailing address

1410 TERRELL MILL RD
MARIETTA GA
30067
US

V. Phone/Fax

Practice location:
  • Phone: 770-984-9000
  • Fax: 770-984-9256
Mailing address:
  • Phone: 770-984-9000
  • Fax: 770-984-9256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN013274
License Number StateGA

VIII. Authorized Official

Name: WILLIAM KAPGAN
Title or Position: OWNER
Credential:
Phone: 770-984-9000