Provider Demographics
NPI:1578766317
Name:BIVINS, DEQUAN
Entity Type:Individual
Prefix:
First Name:DEQUAN
Middle Name:
Last Name:BIVINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 807-A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-3045
Mailing Address - Country:US
Mailing Address - Phone:770-925-9045
Mailing Address - Fax:
Practice Address - Street 1:1455 PLEASANT HILL RD
Practice Address - Street 2:SUITE 807-A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-3045
Practice Address - Country:US
Practice Address - Phone:770-925-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice