Provider Demographics
NPI:1497435770
Name:SHUKRUTA, VLAD (DDS)
Entity Type:Individual
Prefix:
First Name:VLAD
Middle Name:
Last Name:SHUKRUTA
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 1:210 CHEROKEE PL
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-2965
Mailing Address - Country:US
Mailing Address - Phone:678-573-9013
Mailing Address - Fax:
Practice Address - Street 1:210 CHEROKEE PL
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2965
Practice Address - Country:US
Practice Address - Phone:678-573-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1230691223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice