Healthcare Provider Details

I. General information

NPI: 1235224817
Provider Name (Legal Business Name): PETER SEBASTIAN CIMINO III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 MEDICAL CT.
OGLETHORPE GA
31068
US

IV. Provider business mailing address

1011 FORSLING RD.
REYNOLDS GA
31076
US

V. Phone/Fax

Practice location:
  • Phone: 478-472-2325
  • Fax: 478-472-2325
Mailing address:
  • Phone: 478-918-3077
  • Fax: 478-847-2993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number011480
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: