=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992767594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANE A ULETT DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2006
-----------------------------------------------------
Last Update Date | 12/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2045 PEACHTREE RD NE STE 810
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-446-1890
-----------------------------------------------------
Fax | 404-446-1898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 CIRCLE 75 PKWY SE STE 900
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-3084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-426-2171
-----------------------------------------------------
Fax | 404-446-1957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | POD000960
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------