Provider Demographics
NPI:1811006471
Name:IAN, WAUNELLE JACKSON (DDS)
Entity Type:Individual
Prefix:MRS
First Name:WAUNELLE
Middle Name:JACKSON
Last Name:IAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:WAUNELLE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2520 WINDY HILL ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067
Mailing Address - Country:US
Mailing Address - Phone:770-953-4801
Mailing Address - Fax:
Practice Address - Street 1:2520 WINDY HILL ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067
Practice Address - Country:US
Practice Address - Phone:770-953-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice