Provider Demographics
NPI:1710072806
Name:JACQUES, MICHELLE (DDS)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 PEELER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5714
Mailing Address - Country:US
Mailing Address - Phone:770-391-9212
Mailing Address - Fax:770-698-9929
Practice Address - Street 1:1853 PEELER RD
Practice Address - Street 2:SUITE A
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-5714
Practice Address - Country:US
Practice Address - Phone:770-391-9212
Practice Address - Fax:770-698-9929
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice