Provider Demographics
NPI:1497875504
Name:JACKSON, MONTINA GOLPHIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MONTINA
Middle Name:GOLPHIN
Last Name:JACKSON
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 1:2197 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1143
Mailing Address - Country:US
Mailing Address - Phone:404-699-1919
Mailing Address - Fax:404-699-1402
Practice Address - Street 1:2197 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1143
Practice Address - Country:US
Practice Address - Phone:404-699-1919
Practice Address - Fax:404-699-1402
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO107851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00443968AMedicaid