Healthcare Provider Details

I. General information

NPI: 1245249457
Provider Name (Legal Business Name): BRIAN ALEXANDER PUGH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 BRASELTON HWY SUITE 101
DACULA GA
30019-1014
US

IV. Provider business mailing address

3625 BRASELTON HWY SUITE 101
DACULA GA
30019-1014
US

V. Phone/Fax

Practice location:
  • Phone: 770-614-9467
  • Fax: 770-614-9468
Mailing address:
  • Phone: 770-614-9467
  • Fax: 770-614-9468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN012936
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: