Provider Demographics
NPI:1700858032
Name:MORCEAU, ELYSE M (DDS)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:M
Last Name:MORCEAU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:M
Other - Last Name:BERKON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1203 FAWNDALE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3958
Mailing Address - Country:US
Mailing Address - Phone:404-509-4145
Mailing Address - Fax:770-451-5112
Practice Address - Street 1:205 HAWKINS STORE RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6215
Practice Address - Country:US
Practice Address - Phone:770-926-3400
Practice Address - Fax:770-926-6317
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000896629DMedicaid