Healthcare Provider Details

I. General information

NPI: 1760540652
Provider Name (Legal Business Name): PAUL STANLEY KUDYBA JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 NELSON BROGDON BLVD
SUGAR HILL GA
30518
US

IV. Provider business mailing address

4740 NELSON BROGDON BLVD
SUGAR HILL GA
30518
US

V. Phone/Fax

Practice location:
  • Phone: 770-945-5027
  • Fax: 770-945-1362
Mailing address:
  • Phone: 770-945-5027
  • Fax: 770-945-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number9565
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5025
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: