Provider Demographics
NPI:1164687612
Name:ELYSE M. MORCEAU, DDS, PC
Entity type:Organization
Organization Name:ELYSE M. MORCEAU, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO, VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORCEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-926-3400
Mailing Address - Street 1:205 HAWKINS STORE RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6215
Mailing Address - Country:US
Mailing Address - Phone:770-926-3400
Mailing Address - Fax:770-926-6317
Practice Address - Street 1:205 HAWKINS STORE RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6215
Practice Address - Country:US
Practice Address - Phone:770-926-3400
Practice Address - Fax:770-926-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
GADN0088211223P0221X
GADN0092681223P0221X
GADN0123091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00349423CMedicaid
GA00896629DMedicaid
GA000157924BMedicaid