Basic Information
| Provider Information | |||||||||
| NPI: | 1629511407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | MACK | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 SCHATULGA RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319073117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 SCHATULGA RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319073117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2016 | ||||||||
| LastUpdateDate: | 11/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN015140 | GA | Y | Dental Providers | Dentist |
No ID Information.