Provider Demographics
NPI:1801454871
Name:MACK, DAKITA (DO)
Entity type:Individual
Prefix:
First Name:DAKITA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6341 DESHONG DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 120TH AVE NE STE B201
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3038
Practice Address - Country:US
Practice Address - Phone:425-453-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151013499208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery