Provider Demographics
NPI:1053161372
Name:KIMBERLY A PETERS DMD PC
Entity type:Organization
Organization Name:KIMBERLY A PETERS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-294-3004
Mailing Address - Street 1:1000 IRIS DR SW STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6622
Mailing Address - Country:US
Mailing Address - Phone:770-922-1666
Mailing Address - Fax:
Practice Address - Street 1:1000 IRIS DR SW STE A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6622
Practice Address - Country:US
Practice Address - Phone:770-922-1666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN014630OtherDENTAL LICENSE
GA1194166306OtherNPI INDIVIDUAL