Provider Demographics
NPI:1033433610
Name:MAXWELL, JIMMY FOSTER (DMD, PC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:FOSTER
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 AMELIA AVE
Mailing Address - Street 2:PO BOX 727
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 AMELIA AVE
Practice Address - Street 2:POB 727
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4356
Practice Address - Country:US
Practice Address - Phone:229-246-3023
Practice Address - Fax:229-246-3024
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009648122300000X
FLDN9728122300000X
TNDS0000007704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH011407OtherPHARMACY LICENSE
GA00245341A4Medicaid