Provider Demographics
NPI:1326340407
Name:IACULLI, JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:IACULLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-0195
Mailing Address - Country:US
Mailing Address - Phone:678-445-9191
Mailing Address - Fax:678-445-9173
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BUILDING 1100, STE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:678-445-9191
Practice Address - Fax:678-445-9173
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics