Healthcare Provider Details

I. General information

NPI: 1497311823
Provider Name (Legal Business Name): JENNIFER MARIE GEORGIADIS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MARIE KOTSIKONAS

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 RINGWOOD AVE
HASKELL NJ
07420-1343
US

IV. Provider business mailing address

615 PAVONIA AVE APT 3208
JERSEY CITY NJ
07306-2958
US

V. Phone/Fax

Practice location:
  • Phone: 973-839-3434
  • Fax:
Mailing address:
  • Phone: 917-576-4731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI02753800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: