Provider Demographics
NPI:1306930607
Name:SHORT, KEVIN SEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SEAN
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-0599
Mailing Address - Country:US
Mailing Address - Phone:770-781-8650
Mailing Address - Fax:770-781-2953
Practice Address - Street 1:1200 BALD RIDGE MARINA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8494
Practice Address - Country:US
Practice Address - Phone:770-781-8650
Practice Address - Fax:770-781-2953
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0112421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA825012OtherUNITED CONCORDIA
TN4080537OtherBC/BS