Provider Demographics
NPI:1225191935
Name:VINEYARDS DENTAL CARE
Entity Type:Organization
Organization Name:VINEYARDS DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZZUCKELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, DMD
Authorized Official - Phone:770-868-4288
Mailing Address - Street 1:2095 HIGHWAY 211 NW
Mailing Address - Street 2:SUITE 6-A
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-3402
Mailing Address - Country:US
Mailing Address - Phone:770-868-4288
Mailing Address - Fax:770-868-4291
Practice Address - Street 1:2095 HIGHWAY 211 NW
Practice Address - Street 2:SUITE 6-A
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3402
Practice Address - Country:US
Practice Address - Phone:770-868-4288
Practice Address - Fax:770-868-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO 144171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty