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General NPI Number Information
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NPI Number | 1538392493
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Entity Type | Organization
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Legal Business Name | COSMETIC FAMILY DENTISTRY OF ROSWELL
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Dates
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Enumeration Date | 08/26/2009
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Last Update Date | 08/26/2009
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Provider Practice Location Address
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Address Line | 1087 ALPHARETTA ST
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City | ROSWELL
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State | GA
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Zip | 30075-4483
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Country | US
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Telephone | 770-650-0992
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Fax |
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Provider Business Mailing Address
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Address Line | 1087 ALPHARETTA ST
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City | ROSWELL
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State | GA
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Zip | 30075-4483
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Country | US
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Telephone | 770-650-0992
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Fax | 770-650-0061
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH MORRIS WIGGINS JR.
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Credential | D.D.S.
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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 | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN012485
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN012484
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License Number State | GA
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