Provider Demographics
NPI:1225310592
Name:YELISETTY, IRYNA KORNIYENKO (DMD)
Entity Type:Individual
Prefix:DR
First Name:IRYNA
Middle Name:KORNIYENKO
Last Name:YELISETTY
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 1:1475 PEACHTREE PKWY STE C3
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9793
Mailing Address - Country:US
Mailing Address - Phone:470-253-1747
Mailing Address - Fax:
Practice Address - Street 1:1475 PEACHTREE PKWY STE C3
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9793
Practice Address - Country:US
Practice Address - Phone:470-253-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN143371223G0001X
GADN0143371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1225310592OtherGENERAL DENTIST