Healthcare Provider Details

I. General information

NPI: 1689953960
Provider Name (Legal Business Name): JENNIFER ANNE DILLON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 S COLUMBIA DR
DECATUR GA
30030-4103
US

IV. Provider business mailing address

144 S COLUMBIA DR
DECATUR GA
30030-4103
US

V. Phone/Fax

Practice location:
  • Phone: 404-328-7171
  • Fax: 470-355-4795
Mailing address:
  • Phone: 404-328-7171
  • Fax: 470-355-4795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014385
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9101
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: