Provider Demographics
NPI:1134323835
Name:DETIENNE, MARIE ELISABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELISABETH
Last Name:DETIENNE
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 1:1686 EATONTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-4628
Mailing Address - Country:US
Mailing Address - Phone:706-342-0550
Mailing Address - Fax:706-342-3736
Practice Address - Street 1:1686 EATONTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-4628
Practice Address - Country:US
Practice Address - Phone:706-342-0550
Practice Address - Fax:706-342-3736
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013560122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist