Provider Demographics
NPI:1447515093
Name:BUNN, KENNETH DESMOND (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DESMOND
Last Name:BUNN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9579 HIGHWAY 5 STE 701
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1574
Mailing Address - Country:US
Mailing Address - Phone:770-942-2852
Mailing Address - Fax:
Practice Address - Street 1:9579 HIGHWAY 5 STE 701
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1574
Practice Address - Country:US
Practice Address - Phone:770-942-2852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist