Provider Demographics
NPI:1790428068
Name:LUNDI, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LUNDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1563 GA-20
Mailing Address - Street 2:STE 1563
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1563 GA-20
Practice Address - Street 2:STE 1563
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253
Practice Address - Country:US
Practice Address - Phone:404-616-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist