Provider Demographics
NPI:1164502068
Name:MAHAFFEY, MICHAEL JACK (DMD, MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JACK
Last Name:MAHAFFEY
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 EASTBROOK BND
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1530
Mailing Address - Country:US
Mailing Address - Phone:770-487-6439
Mailing Address - Fax:770-487-7539
Practice Address - Street 1:8 EASTBROOK BND
Practice Address - Street 2:SUITE B
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1530
Practice Address - Country:US
Practice Address - Phone:770-487-6439
Practice Address - Fax:770-487-7539
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA124641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics