Provider Demographics
NPI:1376217661
Name:DAVIS, JESSICA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 GRASSY OAT LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-5496
Mailing Address - Country:US
Mailing Address - Phone:678-313-9181
Mailing Address - Fax:
Practice Address - Street 1:1200 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7557
Practice Address - Country:US
Practice Address - Phone:678-805-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1224461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice