Provider Demographics
NPI:1558796896
Name:MUCCIOLI DENTAL, PC
Entity Type:Organization
Organization Name:MUCCIOLI DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:MUCCIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-389-9955
Mailing Address - Street 1:6300 HOSPITAL PKWY
Mailing Address - Street 2:SUITE 275
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1828
Mailing Address - Country:US
Mailing Address - Phone:678-389-9955
Mailing Address - Fax:678-389-9952
Practice Address - Street 1:6300 HOSPITAL PKWY
Practice Address - Street 2:SUITE 275
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1828
Practice Address - Country:US
Practice Address - Phone:678-389-9955
Practice Address - Fax:678-389-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0143781223G0001X
GADN0143791223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty