Provider Demographics
NPI:1003054156
Name:HADER, JESSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:HADER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3648 PEACHTREE RD NE
Mailing Address - Street 2:PENTHOUSE 4-S
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1255
Mailing Address - Country:US
Mailing Address - Phone:404-842-1196
Mailing Address - Fax:404-842-1198
Practice Address - Street 1:3648 PEACHTREE RD NE
Practice Address - Street 2:PENTHOUSE 4-S
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1255
Practice Address - Country:US
Practice Address - Phone:404-842-1196
Practice Address - Fax:404-842-1198
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN006221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist