Provider Demographics
NPI:1033319520
Name:BETANCOURT, MARLYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARLYN
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3756
Mailing Address - Country:US
Mailing Address - Phone:770-539-9110
Mailing Address - Fax:
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE E
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3756
Practice Address - Country:US
Practice Address - Phone:770-539-9110
Practice Address - Fax:678-714-8388
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0113351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice