Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN006221 | GA |
NPI | 1003054156 |
---|---|
Provider Name | Dr. Jesse Hader |
First Address | Atlanta, GA 30319-1255 |
Second Address | Atlanta, GA 30319-1255 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2009 |
Last Update Date | 28/12/2011 |