Provider Demographics
NPI:1336254275
Name:DISMUKE, DEBBIE L
Entity Type:Individual
Prefix:DR
First Name:DEBBIE
Middle Name:L
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1266
Mailing Address - Country:US
Mailing Address - Phone:912-384-2277
Mailing Address - Fax:912-384-7543
Practice Address - Street 1:1305 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2209
Practice Address - Country:US
Practice Address - Phone:912-384-2277
Practice Address - Fax:912-384-7543
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0102131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1336254275Medicare UPIN