Provider Demographics
NPI:1497311823
Name:GEORGIADIS, JENNIFER MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:GEORGIADIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:KOTSIKONAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 PAVONIA AVE APT 3208
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2958
Mailing Address - Country:US
Mailing Address - Phone:917-576-4731
Mailing Address - Fax:
Practice Address - Street 1:909 RINGWOOD AVE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1343
Practice Address - Country:US
Practice Address - Phone:973-839-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027538001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics