Healthcare Provider Details

I. General information

NPI: 1871662668
Provider Name (Legal Business Name): MARIE OLIVIA BASS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 JESSE HILL JR DR SE
ATLANTA GA
30303
US

IV. Provider business mailing address

300 GEMSTONE PLACE
COLLEGE PARK GA
30349-8432
US

V. Phone/Fax

Practice location:
  • Phone: 404-730-1471
  • Fax: 404-730-1475
Mailing address:
  • Phone: 770-991-3323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number009527
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: