Provider Demographics
NPI:1093881021
Name:THREADGILL, JONATHAN MAXWELL CHRISENBERRY (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MAXWELL CHRISENBERRY
Last Name:THREADGILL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JOHNSON FERRY RD BLDG H
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5518
Mailing Address - Country:US
Mailing Address - Phone:678-819-6536
Mailing Address - Fax:678-483-8487
Practice Address - Street 1:1000 JOHNSON FERRY RD BLDG H
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5518
Practice Address - Country:US
Practice Address - Phone:770-977-0364
Practice Address - Fax:678-483-8487
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0143481223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA993983OtherUNITED CONCORDIA