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General NPI Number Information
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NPI Number | 1205014578
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Entity Type | Organization
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Legal Business Name | GWINNETT ORAL & MAXILLOFACIAL SURGERY, PC
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Dates
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Enumeration Date | 02/08/2008
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Last Update Date | 02/08/2008
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Provider Practice Location Address
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Address Line | 171 GWINNETT DR SUITE B
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-5686
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Country | US
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Telephone | 770-995-7960
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Fax |
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Provider Business Mailing Address
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Address Line | 171 GWINNETT DR SUITE B
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-5686
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Country | US
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Telephone | 770-995-7960
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. S LYLE ZUCK
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Credential | DMD, MD
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Telephone | 770-995-7960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN013444
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License Number State | GA
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