MEDICARE: DR. JENNIFER MARIE GEORGIADIS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	22DI02753800	NJ

General Provider Information

NPI Number	:	1497311823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MARIE GEORGIADIS DDS

Provider Business Mailing Address
First Line	:	615 PAVONIA AVE APT 3208
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-2958
Country	:	US
Telephone Number	:	917-576-4731
Fax Number	:

Provider Business Practice Location Address
First Line	:	909 RINGWOOD AVE
Second Line	:
City	:	HASKELL
State	:	NJ
Zip	:	07420-1343
Country	:	US
Telephone Number	:	973-839-3434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2019
Last Update Date	:	05/10/2019

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