NPIMap

Organization Active NPI

Modern Cosmetic Dental Care, LLC

  • Dental Clinic/Center
  • Covington, GA
National Provider Identifier
1992103428
Registry record updated Dec 16, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
License
DN011417 Issued in GA
Legal business name
MODERN COSMETIC DENTAL CARE, LLC
Practice address
1750 Highway 11
Suite B
Covington, GA 30014
Phone
(678) 592-1125
NPI assigned
Dec 16, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Tom Mazzuckelli, D.M.D.
Title
Manager
Phone
(678) 592-1125

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X DN011417 GA Primary

Addresses

Primary practice location

1750 Highway 11
Suite B
Covington, GA 30014

Mailing address

1750 Highway 11
Suite B
Covington, GA 30014
Phone (678) 592-1125

National Provider Directory

National Provider Directory

Locations

1750 Highway 11 S
Ste B
Covington, GA 30014
Phone (678) 592-1125

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1418688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418688000000",
    "number": "1992103428",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1750 HIGHWAY 11",
            "address_2": "SUITE B",
            "city": "COVINGTON",
            "state": "GA",
            "postal_code": "30014",
            "telephone_number": "678-592-1125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1750 HIGHWAY 11",
            "address_2": "SUITE B",
            "city": "COVINGTON",
            "state": "GA",
            "postal_code": "30014",
            "telephone_number": "678-592-1125"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN COSMETIC DENTAL CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-16",
        "last_updated": "2014-12-16",
        "status": "A",
        "authorized_official_last_name": "MAZZUCKELLI",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "678-592-1125",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "GA",
            "license": "DN011417",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Covington, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.