Provider Demographics
NPI:1316100738
Name:DERRICK-GRIFFITH, ALAN A (DMD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:A
Last Name:DERRICK-GRIFFITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:ALAN
Other - Middle Name:A
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2802 CLEARWATER TER SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2484
Mailing Address - Country:US
Mailing Address - Phone:470-595-3540
Mailing Address - Fax:
Practice Address - Street 1:2802 CLEARWATER TER SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2484
Practice Address - Country:US
Practice Address - Phone:470-595-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5375122300000X
GADN0139981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist