Provider Demographics
NPI:1619655230
Name:WARNER, IVAN MACHAI
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:MACHAI
Last Name:WARNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 JOHNSON FERRY RD STE 660
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2772
Mailing Address - Country:US
Mailing Address - Phone:770-973-6494
Mailing Address - Fax:
Practice Address - Street 1:1225 JOHNSON FERRY RD STE 660
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2772
Practice Address - Country:US
Practice Address - Phone:770-973-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1234931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice