Provider Demographics
NPI:1689839805
Name:HADIBE, JEREMY ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ERIC
Last Name:HADIBE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 POWERS FERRY RD SE STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-9417
Mailing Address - Country:US
Mailing Address - Phone:770-980-9404
Mailing Address - Fax:
Practice Address - Street 1:1545 POWERS FERRY RD SE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9417
Practice Address - Country:US
Practice Address - Phone:709-809-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0376111223S0112X
GADN0156171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080804Medicaid
AZ030073Medicare Oscar/Certification
AZ080804Medicaid