Provider Demographics
NPI:1275916728
Name:DELASH, JACQUELINE (DMD, MBA, MPH)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:DELASH
Suffix:
Gender:F
Credentials:DMD, MBA, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DR GC- 1012
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-7913
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:98 N PARK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1645
Practice Address - Country:US
Practice Address - Phone:770-461-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014990122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist