Organization
MODERN COSMETIC DENTAL CARE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TOM MAZZUCKELLI D.M.D. (MANAGER)
(678) 592-1125
Entity
Organization
Contact information
Practice address
1750 HIGHWAY 11, SUITE B, COVINGTON, GA 30014
(678) 592-1125
Mailing address
1750 HIGHWAY 11, SUITE B, COVINGTON, GA 30014
(678) 592-1125
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
DN011417
GA
Other
Enumeration date
12/16/2014
Last updated
12/16/2014
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