Provider Demographics
NPI:1164525390
Name:JONES LATHON, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:JONES LATHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 N ROCKY POINT DR
Mailing Address - Street 2:SUITE 1000-CREDENTIALING
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 HIGHWAY 34 E STE A1
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2191
Practice Address - Country:US
Practice Address - Phone:770-254-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011657122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist