Healthcare Provider Details

I. General information

NPI: 1275677932
Provider Name (Legal Business Name): MARLON ANTONIO BROWN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/19/2021
Certification Date: 06/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 GATEWAY LN STE 300
BETHLEHEM GA
30620-1852
US

IV. Provider business mailing address

3400 GREENSIDE CT
DACULA GA
30019-4645
US

V. Phone/Fax

Practice location:
  • Phone: 775-527-3067
  • Fax:
Mailing address:
  • Phone: 775-527-3067
  • Fax: 775-334-4361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number011372
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN011372
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: