Provider Demographics
NPI:1316243389
Name:KENNESTONE PERIODONTICS OF MARIETTA, PC
Entity type:Organization
Organization Name:KENNESTONE PERIODONTICS OF MARIETTA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-422-0642
Mailing Address - Street 1:2070 S PARK PL SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2045
Mailing Address - Country:US
Mailing Address - Phone:770-952-5432
Mailing Address - Fax:770-952-3011
Practice Address - Street 1:611 CAMPBELL HILL ST NW
Practice Address - Street 2:SUITE 102
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1386
Practice Address - Country:US
Practice Address - Phone:770-422-0642
Practice Address - Fax:770-422-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA113841223P0300X
GA107421223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982798716OtherPERSONAL NPI NUMBER
GA1811082183OtherPERSONAL NPI NUMBER