Provider Demographics
NPI:1699746503
Name:ZUCK, STACEY LYLE (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYLE
Last Name:ZUCK
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:945 RIVER CENTRE PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7340
Mailing Address - Country:US
Mailing Address - Phone:770-995-7960
Mailing Address - Fax:770-995-7367
Practice Address - Street 1:945 RIVER CENTRE PL
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7340
Practice Address - Country:US
Practice Address - Phone:770-995-7960
Practice Address - Fax:770-995-7367
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0314441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery