Healthcare Provider Details

I. General information

NPI: 1245949262
Provider Name (Legal Business Name): PAUL KANESHIRO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ROCK SPRINGS RD
SMYRNA TN
37167-6141
US

IV. Provider business mailing address

336 PARK CREEK RDG
WOODSTOCK GA
30188-2158
US

V. Phone/Fax

Practice location:
  • Phone: 615-220-6161
  • Fax: 615-220-6116
Mailing address:
  • Phone: 808-351-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberN127582
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12827
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: