Dereka McKissack McKissack
Dental Assistant in Stone Mountain, GA. Individual provider (NPI-1).
NPI number1124469705
StatusActive
Last updated in NPPESJul 11, 2013
Details
- NPI
- 1124469705
- Entity type
- Individual (NPI-1)
- Name
- Ms. Dereka McKissack McKissack
- Sex
- Female
- Sole proprietor
- Yes
- Enumeration date
- Jul 11, 2013
- Last updated
- Jul 11, 2013
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 126800000X | Dental Assistant | – | – | Yes |
Practice location
374 N Deshon Rd Ste DStone Mountain, GA 30087-4827
Phone 770-469-4192 · Fax 770-469-4195
Mailing address
374 N Deshon Rd Ste DStone Mountain, GA 30087-4827
Phone 770-469-4192 · Fax 770-469-4195
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