Healthcare Provider Details

I. General information

NPI: 1699746503
Provider Name (Legal Business Name): STACEY LYLE ZUCK D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 RIVER CENTRE PL SUITE 100
LAWRENCEVILLE GA
30043-7340
US

IV. Provider business mailing address

945 RIVER CENTRE PL SUITE 100
LAWRENCEVILLE GA
30043-7340
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-7960
  • Fax: 770-995-7367
Mailing address:
  • Phone: 770-995-7960
  • Fax: 770-995-7367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN031444
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: