=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427186204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA WALL MORIN D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 12/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 SEVEN HILLS BLVD SUITE 107
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-0524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-574-4837
-----------------------------------------------------
Fax | 678-828-5409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 SEVEN HILLS BLVD SUITE 107
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-0524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-574-4837
-----------------------------------------------------
Fax | 678-828-5409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN013178
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------