Provider Demographics
NPI:1760624332
Name:COKER, NEYSA ALICE (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:NEYSA
Middle Name:ALICE
Last Name:COKER
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 GOLF CREST DR STE 209
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-2698
Mailing Address - Country:US
Mailing Address - Phone:770-672-5629
Mailing Address - Fax:
Practice Address - Street 1:598 NANCY ST NW STE 150
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1377
Practice Address - Country:US
Practice Address - Phone:770-672-5629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA404268068Medicaid