Provider Demographics
NPI:1023110558
Name:MAYFIELD, DALE GARY (DMD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:GARY
Last Name:MAYFIELD
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 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:770-716-1725
Mailing Address - Fax:
Practice Address - Street 1:4324 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1208
Practice Address - Country:US
Practice Address - Phone:404-289-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000907255AMedicaid