Provider Demographics
NPI:1831740786
Name:ANDREUCCETTI, JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:ANDREUCCETTI
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 1:421 CLAIRE PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1972
Mailing Address - Country:US
Mailing Address - Phone:630-453-2511
Mailing Address - Fax:
Practice Address - Street 1:160 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2871
Practice Address - Country:US
Practice Address - Phone:478-743-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0159621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice