Provider Demographics
NPI:1861008294
Name:ZUDEKOFF, KELLI ERIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:ERIN
Last Name:ZUDEKOFF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 CRESTON HILL WAY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5672
Mailing Address - Country:US
Mailing Address - Phone:678-491-1032
Mailing Address - Fax:
Practice Address - Street 1:350 TOWN CENTER AVE STE 301
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6914
Practice Address - Country:US
Practice Address - Phone:678-448-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016144-T122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist