Healthcare Provider Details

I. General information

NPI: 1467646729
Provider Name (Legal Business Name): DOUGLAS GARLAND HISER DMD, MS, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ELM ST SUITE 101
CUMMING GA
30040-8233
US

IV. Provider business mailing address

285 ELM ST SUITE 101
CUMMING GA
30040-8233
US

V. Phone/Fax

Practice location:
  • Phone: 770-888-7798
  • Fax: 770-888-1474
Mailing address:
  • Phone: 770-888-7798
  • Fax: 770-888-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number011988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: