Provider Demographics
NPI:1568683654
Name:DIVERSI, JENNIFER IRENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:IRENE
Last Name:DIVERSI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 EAGLES POINTE PARKWAY
Mailing Address - Street 2:STE 110
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-507-6100
Mailing Address - Fax:770-507-5988
Practice Address - Street 1:125 EAGLES POINTE PARKWAY
Practice Address - Street 2:STE 110
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-507-6100
Practice Address - Fax:770-507-5988
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0105391223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics