MEDICARE: STACEY COHEN WEITZNER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN014264	GA

General Provider Information

NPI Number	:	1487943775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY COHEN WEITZNER DMD

Provider Business Mailing Address
First Line	:	4939 LOWER ROSWELL RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30068-4338
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4939 LOWER ROSWELL RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30068-4338
Country	:	US
Telephone Number	:	770-973-0544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	04/21/2015

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