Healthcare Provider Details

I. General information

NPI: 1447473947
Provider Name (Legal Business Name): ASHISH KUKREJA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 W LANIER AVE
FAYETTEVILLE GA
30214-7649
US

IV. Provider business mailing address

451 HAROLD AVE NE
ATLANTA GA
30307-1739
US

V. Phone/Fax

Practice location:
  • Phone: 678-836-2128
  • Fax: 770-441-0299
Mailing address:
  • Phone: 504-914-8748
  • Fax: 770-441-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013129
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: