Healthcare Provider Details

I. General information

NPI: 1598819690
Provider Name (Legal Business Name): MARIETTA PUBLIC HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

IV. Provider business mailing address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-2361
  • Fax:
Mailing address:
  • Phone: 770-514-2361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN011004
License Number StateGA

VIII. Authorized Official

Name: MR. TYLER CARLSON
Title or Position: ADMINISTRATION DIRECTOR
Credential:
Phone: 770-514-2342