Provider Demographics
NPI:1184769408
Name:DARTY, PETER MADRID (DMD,PHARMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MADRID
Last Name:DARTY
Suffix:
Gender:M
Credentials:DMD,PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 HABERSHAM GATE DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8076
Mailing Address - Country:US
Mailing Address - Phone:770-887-3602
Mailing Address - Fax:
Practice Address - Street 1:2015 HABERSHAM GATE DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8076
Practice Address - Country:US
Practice Address - Phone:770-887-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0107691223G0001X
GARPH014665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No183500000XPharmacy Service ProvidersPharmacist