Provider Demographics
NPI:1902352149
Name:PESUT, CHRISTOPHER DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DANIEL
Last Name:PESUT
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:SAGE DENTAL OF TUCKER
Mailing Address - Street 2:4280 LAVISTA RD STE C117
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:678-688-4811
Mailing Address - Fax:
Practice Address - Street 1:SAGE DENTAL OF TUCKER
Practice Address - Street 2:4280 LAVISTA RD STE C117
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:678-688-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1233921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics