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General NPI Number Information
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NPI Number | 1528195195
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Entity Type | Organization
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Legal Business Name | PEACHTREE PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 310 STEVENS ENTRY
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-1325
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Country | US
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Telephone | 770-486-0054
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Fax | 770-486-8050
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Provider Business Mailing Address
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Address Line | 310 STEVENS ENTRY
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-1325
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Country | US
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Telephone | 770-486-0054
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Fax | 770-486-8050
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Authorized Official
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Title or Position | DENTIST
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Name | DR. BARRY K MARCUM
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Credential | D.M.D.
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Telephone | 770-486-0054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 12275
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 11234
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License Number State | GA
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