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General NPI Number Information
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NPI Number | 1417204447
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Entity Type | Individual
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Provider Name | JERRY EUGENE NUTT DDS
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Gender | Male
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Dates
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Enumeration Date | 08/09/2012
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Last Update Date | 08/09/2012
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Provider Practice Location Address
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Address Line | 1545 POWERS FERRY RD SE 220
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City | MARIETTA
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State | GA
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Zip | 30067-9412
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Country | US
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Telephone | 770-980-9404
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Fax | 770-951-8773
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Provider Business Mailing Address
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Address Line | 217 MAIN ST
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City | DESTIN
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State | FL
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Zip | 32541-2503
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Country | US
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Telephone | 850-837-0696
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Fax | 866-666-9712
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN008291
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License Number State | GA
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