Provider Demographics
NPI:1083864250
Name:BROWN, CHASTITY MOORE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHASTITY
Middle Name:MOORE
Last Name:BROWN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:CHASTITY
Other - Middle Name:BRIANNA
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1520 LUCKY STREET
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30233
Mailing Address - Country:US
Mailing Address - Phone:770-227-0223
Mailing Address - Fax:770-228-5564
Practice Address - Street 1:1520 LUCKY STREET
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30233
Practice Address - Country:US
Practice Address - Phone:770-227-0223
Practice Address - Fax:770-228-5564
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA137071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice