Provider Demographics
NPI:1073146429
Name:DESETA, JULIA GRACE (DC)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:GRACE
Last Name:DESETA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5456 BETHELVIEW RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8612
Mailing Address - Country:US
Mailing Address - Phone:770-406-8208
Mailing Address - Fax:
Practice Address - Street 1:5456 BETHELVIEW RD STE 105
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8612
Practice Address - Country:US
Practice Address - Phone:770-406-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3683111N00000X
GACHIR010400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor