Provider Demographics
NPI:1255640082
Name:DENISE P NOEL
Entity type:Organization
Organization Name:DENISE P NOEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTISIT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:NOEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-953-6520
Mailing Address - Street 1:618 N HOUSTON LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028
Mailing Address - Country:US
Mailing Address - Phone:478-956-6520
Mailing Address - Fax:
Practice Address - Street 1:618 N HOUSTON LAKE BLVD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31028-1010
Practice Address - Country:US
Practice Address - Phone:478-956-6520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA979736219AMedicaid
GA1982750766OtherINDIVIDUAL NPI