Healthcare Provider Details

I. General information

NPI: 1629584586
Provider Name (Legal Business Name): HERRIN CPDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3006 CLAIRMONT RD NE STE 100
BROOKHAVEN GA
30329-1602
US

IV. Provider business mailing address

PO BOX 370160
DECATUR GA
30037-0160
US

V. Phone/Fax

Practice location:
  • Phone: 844-682-4737
  • Fax: 404-521-4044
Mailing address:
  • Phone: 404-403-4567
  • Fax: 404-521-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013021
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014898
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014185
License Number StateGA

VIII. Authorized Official

Name: DR. MARCUS QURAN POLK
Title or Position: PRACTICE MANAGER
Credential: MD
Phone: 404-403-4567