Provider Demographics
NPI:1144219619
Name:SHORT, GEORGE M (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:33 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2042
Mailing Address - Country:US
Mailing Address - Phone:731-668-3411
Mailing Address - Fax:731-668-3410
Practice Address - Street 1:33 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2042
Practice Address - Country:US
Practice Address - Phone:731-668-3411
Practice Address - Fax:731-668-3410
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDS24211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3219278Medicaid