Provider Demographics
NPI:1023019338
Name:PURCELL, DENT W (MD)
Entity Type:Individual
Prefix:DR
First Name:DENT
Middle Name:W
Last Name:PURCELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5635
Mailing Address - Country:US
Mailing Address - Phone:770-693-2622
Mailing Address - Fax:770-693-6039
Practice Address - Street 1:410 WILLOWPEG WAY
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-9157
Practice Address - Country:US
Practice Address - Phone:912-826-5465
Practice Address - Fax:912-826-4851
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 12545174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00060607AMedicaid
GA00060607AMedicaid
D62370Medicare UPIN