Healthcare Provider Details

I. General information

NPI: 1205870284
Provider Name (Legal Business Name): KENNETH KIRBY HUTCHINSON D,M.D., F.A.G.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1569-A JANMAR RD.
SNELLVILLE GA
30078-5780
US

IV. Provider business mailing address

1569-A JANMAR RD.
SNELLVILLE GA
30078-5780
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-7923
  • Fax: 678-990-6954
Mailing address:
  • Phone: 770-979-7923
  • Fax: 678-990-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9640
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: