Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN011911 | GA |
N | 1223P0221X | Pediatric Dentist | DN011911 | GA |
NPI | 1043247257 |
---|---|
Provider Name | Jack Thomas JR. |
First Address | Atlanta, GA 30342-4014 |
Second Address | Atlanta, GA 30342-4014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 31/08/2021 |