Healthcare Provider Details

I. General information

NPI: 1043247257
Provider Name (Legal Business Name): JACK THOMAS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

IV. Provider business mailing address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2072
  • Fax: 404-785-5892
Mailing address:
  • Phone: 404-785-2072
  • Fax: 404-785-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN011911
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN011911
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: