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General NPI Number Information
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NPI Number | 1023264322
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Entity Type | Organization
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Legal Business Name | COSMETIC AND FAMILY DENTISTRY OF MARIETTA
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Dates
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Enumeration Date | 08/18/2008
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Last Update Date | 08/18/2008
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Provider Practice Location Address
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Address Line | 1611 SANDS PL SE STE 100
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City | MARIETTA
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State | GA
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Zip | 30067-8704
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Country | US
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Telephone | 770-226-0008
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Fax | 770-226-0700
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Provider Business Mailing Address
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Address Line | PO BOX 7718
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City | MARIETTA
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State | GA
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Zip | 30065-1718
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Country | US
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Telephone | 770-226-0008
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Fax | 770-226-0700
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Authorized Official
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Title or Position | DR./DENTIST
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Name | DR. KENNETH MORRIS WIGGINS JR.
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Credential | DDS
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Telephone | 770-226-0008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN012484
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN012485
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License Number State | GA
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