Provider Demographics
NPI:1528195195
Name:PEACHTREE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PEACHTREE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARCUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-486-0054
Mailing Address - Street 1:310 STEVENS ENTRY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1325
Mailing Address - Country:US
Mailing Address - Phone:770-486-0054
Mailing Address - Fax:770-486-8050
Practice Address - Street 1:310 STEVENS ENTRY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1325
Practice Address - Country:US
Practice Address - Phone:770-486-0054
Practice Address - Fax:770-486-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA112341223P0221X
GA122751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty