Provider Demographics
NPI:1194772053
Name:PLUMMER, KEVIN D (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
Last Name:PLUMMER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 15TH ST
Mailing Address - Street 2:GC-1024
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-9633
Mailing Address - Fax:706-723-0266
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:GC-1024
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-9633
Practice Address - Fax:706-721-0266
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0090881223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000877764AMedicaid
SCZG9088Medicaid
GA000877764AMedicaid