Provider Demographics
NPI:1497438220
Name:CHEMMALAKUZHY, RON (DMD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:CHEMMALAKUZHY
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 1:1021 NASH LEE DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7632
Mailing Address - Country:US
Mailing Address - Phone:770-356-4342
Mailing Address - Fax:
Practice Address - Street 1:222 CHAMBLESS LN
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:GA
Practice Address - Zip Code:31811-6144
Practice Address - Country:US
Practice Address - Phone:706-903-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist