=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750556965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORRETTA STEPHANIE BROWN-SPENCER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2008
-----------------------------------------------------
Last Update Date | 04/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3285 HOUSTON AVE
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31206-2342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-784-7572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 AUDREY WAY
-----------------------------------------------------
City | KATHLEEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31047-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-988-4787
-----------------------------------------------------
Fax | 478-987-5376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 011498
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------