MEDICARE: DR. MARY KRISTIN JORGENSEN 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	122300000X	Dentist	10968	GA

General Provider Information

NPI Number	:	1821091521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KRISTIN JORGENSEN DDS

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

Provider Business Practice Location Address
First Line	:	224 SHALLOWFORD RD NW
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30504-4171
Country	:	US
Telephone Number	:	770-536-1170
Fax Number	:	770-536-4653

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	02/16/2011

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