Provider Demographics
NPI:1003088592
Name:MAZZUCHELLI, THOMAS JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:MAZZUCHELLI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SHAWNEE LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7316
Mailing Address - Country:US
Mailing Address - Phone:770-973-6520
Mailing Address - Fax:
Practice Address - Street 1:58 SHAWNEE LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7316
Practice Address - Country:US
Practice Address - Phone:770-973-6520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0120651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice