Provider Demographics
NPI:1316570906
Name:JONES, SHUNDERICKA
Entity Type:Individual
Prefix:
First Name:SHUNDERICKA
Middle Name:
Last Name:JONES
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 1:6680 POLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6485
Mailing Address - Country:US
Mailing Address - Phone:678-488-3062
Mailing Address - Fax:
Practice Address - Street 1:4718 ASHFORD DUNWOODY RD STE 400
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-5577
Practice Address - Country:US
Practice Address - Phone:770-625-1968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASTUDENT1223G0001X
GADN1222661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice