Healthcare Provider Details

I. General information

NPI: 1740980507
Provider Name (Legal Business Name): MARISA ELLIOTT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLD MILTON PKWY STE A430
ALPHARETTA GA
30005-3763
US

IV. Provider business mailing address

3400 OLD MILTON PKWY STE A430
ALPHARETTA GA
30005-3763
US

V. Phone/Fax

Practice location:
  • Phone: 770-410-7532
  • Fax:
Mailing address:
  • Phone: 770-410-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN123146
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: