Provider Demographics
NPI:1588092407
Name:DAUTOVIC, MERIDITH LONG (DMD, MS)
Entity type:Individual
Prefix:
First Name:MERIDITH
Middle Name:LONG
Last Name:DAUTOVIC
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE
Mailing Address - Street 2:SUITE 2130
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6401
Mailing Address - Country:US
Mailing Address - Phone:770-850-9119
Mailing Address - Fax:
Practice Address - Street 1:3350 RIVERWOOD PKWY SE
Practice Address - Street 2:SUITE 2130
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-6401
Practice Address - Country:US
Practice Address - Phone:770-850-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics