Healthcare Provider Details

I. General information

NPI: 1548370224
Provider Name (Legal Business Name): ANTHONY G DELUKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 LANIER AVE W BLDG 2
FAYETTEVILLE GA
30214-7649
US

IV. Provider business mailing address

2501 WINSLOW DR NE
ATLANTA GA
30305-3742
US

V. Phone/Fax

Practice location:
  • Phone: 678-836-2128
  • Fax:
Mailing address:
  • Phone: 716-998-3463
  • Fax: 716-998-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12558
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number34336
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN122764
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: