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General NPI Number Information
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NPI Number | 1891905683
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Entity Type | Individual
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Provider Name | ULYSSES LUTHER MARABLE III DMD
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Gender | Male
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 07/08/2013
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Provider Practice Location Address
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Address Line | 1030 PEACH PKWY SUITE 99
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City | FORT VALLEY
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State | GA
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Zip | 31030-8181
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Country | US
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Telephone | 478-825-3000
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Fax | 478-825-3099
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Provider Business Mailing Address
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Address Line | PO BOX 1057
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City | FORT VALLEY
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State | GA
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Zip | 31030-1057
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Country | US
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Telephone | 478-825-3000
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Fax | 478-825-3099
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN013223
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License Number State | GA
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