1821091521 NPI number — DR. MARY KRISTIN JORGENSEN DDS

Table of content: DR. MARY KRISTIN JORGENSEN DDS (NPI 1821091521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821091521 NPI number — DR. MARY KRISTIN JORGENSEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORGENSEN
Provider First Name:
MARY
Provider Middle Name:
KRISTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NIEMCZYK
Provider Other First Name:
MARY
Provider Other Middle Name:
KRISTIN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821091521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4707 MARTIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWERY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30542-3508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-965-1301
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 SHALLOWFORD RD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30504-4171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-536-1170
Provider Business Practice Location Address Fax Number:
770-536-4653
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  10968 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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