Provider Demographics
NPI:1043247257
Name:THOMAS, JACK JR (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:THOMAS
Suffix:JR
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 1:5461 MERIDIAN MARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4014
Mailing Address - Country:US
Mailing Address - Phone:404-785-2072
Mailing Address - Fax:404-785-5892
Practice Address - Street 1:5461 MERIDIAN MARK RD STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4014
Practice Address - Country:US
Practice Address - Phone:404-785-2072
Practice Address - Fax:404-785-5892
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011911122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist