Healthcare Provider Details

I. General information

NPI: 1316243389
Provider Name (Legal Business Name): KENNESTONE PERIODONTICS OF MARIETTA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 CAMPBELL HILL ST NW SUITE 102
MARIETTA GA
30060-1386
US

IV. Provider business mailing address

2070 S PARK PL SE SUITE 200
ATLANTA GA
30339-2045
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-0642
  • Fax: 770-422-0643
Mailing address:
  • Phone: 770-952-5432
  • Fax: 770-952-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number11384
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10742
License Number StateGA

VIII. Authorized Official

Name: DR. PETER C SHATZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 770-422-0642