Healthcare Provider Details

I. General information

NPI: 1629150784
Provider Name (Legal Business Name): JOHN DANIEL HULSEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 KILLIAN HILL RD SW STE 100
LILBURN GA
30047-8976
US

IV. Provider business mailing address

127 DAISY MEADOW TRL
LAWRENCEVILLE GA
30044-4686
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-3966
  • Fax:
Mailing address:
  • Phone: 678-377-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011438
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3268
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: