Provider Demographics
NPI:1952538928
Name:DOORNBOS, MARY WOLFE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:WOLFE
Last Name:DOORNBOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ADDISON
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2227 AUSTIN LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3381
Mailing Address - Country:US
Mailing Address - Phone:706-518-3032
Mailing Address - Fax:
Practice Address - Street 1:135 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 2210
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4942
Practice Address - Country:US
Practice Address - Phone:404-353-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138861223G0001X, 1223P0221X
KY8938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist