=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902697733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC ROCCO MACCHIAVERNA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 09/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 N HIGHLAND AVE NE STE 260
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-589-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2055 HOWARD CIR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-600-6910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN123781
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------