Provider Demographics
NPI:1316571318
Name:COPELAN, MACY MALCOM (DMD)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:MALCOM
Last Name:COPELAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:ELIZABETH
Other - Last Name:MALCOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:179 GARRETT WAY NW
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2318
Mailing Address - Country:US
Mailing Address - Phone:478-453-3004
Mailing Address - Fax:
Practice Address - Street 1:179 GARRETT WAY NW
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2318
Practice Address - Country:US
Practice Address - Phone:478-453-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016074390200000X, 1223G0001X
GAFC9804229390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program