Provider Demographics
NPI:1760541841
Name:MAZZUCKELLI, THOMAS J (PHD, DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:MAZZUCKELLI
Suffix:
Gender:M
Credentials:PHD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11255 PARSONS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1703
Mailing Address - Country:US
Mailing Address - Phone:770-569-1350
Mailing Address - Fax:770-569-1392
Practice Address - Street 1:11255 PARSONS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-1703
Practice Address - Country:US
Practice Address - Phone:770-569-1350
Practice Address - Fax:770-569-1392
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO 114171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice