Provider Demographics
NPI:1366780058
Name:PRILUCK, JEFFREY GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GLENN
Last Name:PRILUCK
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 1:5548 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:770-393-9450
Mailing Address - Fax:770-392-0647
Practice Address - Street 1:5548 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-393-9450
Practice Address - Fax:770-392-0647
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8214122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist