Provider Demographics
NPI:1689354219
Name:ANTHONY, JACQUELINE PAULETTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:PAULETTE
Last Name:ANTHONY
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 1:3287 WEATHERED WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-2469
Mailing Address - Country:US
Mailing Address - Phone:404-353-1601
Mailing Address - Fax:
Practice Address - Street 1:854 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6514
Practice Address - Country:US
Practice Address - Phone:770-320-9882
Practice Address - Fax:770-320-9884
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1231751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice