Provider Demographics
NPI:1265722219
Name:NUKOA FAMILY DENTISTRY
Entity type:Organization
Organization Name:NUKOA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-813-0777
Mailing Address - Street 1:3705 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4335
Mailing Address - Country:US
Mailing Address - Phone:770-813-0777
Mailing Address - Fax:770-813-1023
Practice Address - Street 1:3705 OLD NORCROSS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4335
Practice Address - Country:US
Practice Address - Phone:770-813-0777
Practice Address - Fax:770-813-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA626075029AMedicaid