Healthcare Provider Details

I. General information

NPI: 1205014578
Provider Name (Legal Business Name): GWINNETT ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GWINNETT DR SUITE B
LAWRENCEVILLE GA
30045-5686
US

IV. Provider business mailing address

171 GWINNETT DR SUITE B
LAWRENCEVILLE GA
30045-5686
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-7960
  • Fax:
Mailing address:
  • Phone: 770-995-7960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013444
License Number StateGA

VIII. Authorized Official

Name: DR. S LYLE ZUCK
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 770-995-7960