Healthcare Provider Details

I. General information

NPI: 1982916755
Provider Name (Legal Business Name): JEFFREY MICHAEL SEGNERE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 EAGLE DR SUITE 120
WOODSTOCK GA
30189-6994
US

IV. Provider business mailing address

2054 EAGLE DR SUITE 120
WOODSTOCK GA
30189-6994
US

V. Phone/Fax

Practice location:
  • Phone: 770-635-0350
  • Fax:
Mailing address:
  • Phone: 770-635-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1855497
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN014488
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: