Provider Demographics
NPI:1538392493
Name:COSMETIC FAMILY DENTISTRY OF ROSWELL
Entity type:Organization
Organization Name:COSMETIC FAMILY DENTISTRY OF ROSWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-226-0008
Mailing Address - Street 1:1087 ALPHARETTA ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4483
Mailing Address - Country:US
Mailing Address - Phone:770-650-0992
Mailing Address - Fax:770-650-0061
Practice Address - Street 1:1087 ALPHARETTA ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4483
Practice Address - Country:US
Practice Address - Phone:770-650-0992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012485261QD0000X
GADN012484261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA329140584AMedicaid
GA829858019AMedicaid