Healthcare Provider Details

I. General information

NPI: 1023019338
Provider Name (Legal Business Name): DENT W. PURCELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 WILLOWPEG WAY
RINCON GA
31326-9157
US

IV. Provider business mailing address

2864 JOHNSON FERRY RD SUITE 150
MARIETTA GA
30062-5635
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-5465
  • Fax: 912-826-4851
Mailing address:
  • Phone: 770-693-2622
  • Fax: 770-693-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberGA 12545
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: