Provider Demographics
NPI:1326290644
Name:VIRUET, ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VIRUET
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 1:218 QUARTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3547
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:218 QUARTERMAN ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3547
Practice Address - Country:US
Practice Address - Phone:912-287-0301
Practice Address - Fax:912-287-1568
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12878122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145286AMedicaid