Healthcare Provider Details

I. General information

NPI: 1063732691
Provider Name (Legal Business Name): MARC BRANDON ALLRED DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2010
Last Update Date: 06/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 S 8TH ST
GRIFFIN GA
30224-4818
US

IV. Provider business mailing address

743 S 8TH ST
GRIFFIN GA
30224-4818
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-6101
  • Fax: 770-228-6170
Mailing address:
  • Phone: 770-228-6101
  • Fax: 770-228-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014094
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: