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General NPI Number Information
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NPI Number | 1700107729
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Entity Type | Individual
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Provider Name | TERESA MARIE DECENZO-VERBETEN O.D.
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Gender | Female
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Dates
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Enumeration Date | 06/14/2010
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Last Update Date | 06/14/2010
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Provider Practice Location Address
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Address Line | 11460 JOHNS CREEK PKWY
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City | DULUTH
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State | GA
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Zip | 30097-1518
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Country | US
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Telephone | 678-415-3513
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Fax | 678-415-3815
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Provider Business Mailing Address
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Address Line | 5135 WILD GINGER CV
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City | NORCROSS
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State | GA
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Zip | 30092-5145
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Country | US
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Telephone | 678-415-3513
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Fax | 678-415-3815
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT001643
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License Number State | GA
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