Provider Demographics
NPI:1427150622
Name:BAERTLEIN, ELISABETH
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:BAERTLEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 N ROCKY POINT DR
Mailing Address - Street 2:SUITE 1000-CREDENTIALING
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4463 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8229
Practice Address - Country:US
Practice Address - Phone:678-445-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice