Provider Demographics
NPI:1275677932
Name:BROWN, MARLON ANTONIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:ANTONIO
Last Name:BROWN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GREENSIDE CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4645
Mailing Address - Country:US
Mailing Address - Phone:775-527-3067
Mailing Address - Fax:775-334-4361
Practice Address - Street 1:118 GATEWAY LN STE 300
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-1852
Practice Address - Country:US
Practice Address - Phone:775-527-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011372122300000X
GADN0113721223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004716904Medicaid