Provider Demographics
NPI:1629146469
Name:INNISS, DEXTER P (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:P
Last Name:INNISS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 JULIEN OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:770-922-2714
Mailing Address - Fax:
Practice Address - Street 1:1360 DOGWOOD DR SE
Practice Address - Street 2:SUITE 202B
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5075
Practice Address - Country:US
Practice Address - Phone:770-760-7566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice