Provider Demographics
NPI:1679669683
Name:PEALOCK, BILLY S (DMD)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:S
Last Name:PEALOCK
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 1:3059 LAWRENCEVILLE HWY STE D
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6426
Mailing Address - Country:US
Mailing Address - Phone:770-931-9996
Mailing Address - Fax:770-931-1984
Practice Address - Street 1:3059 LAWRENCEVILLE HWY STE D
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6426
Practice Address - Country:US
Practice Address - Phone:770-931-9996
Practice Address - Fax:770-931-1984
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA114441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice