Provider Demographics
NPI:1821091521
Name:JORGENSEN, MARY KRISTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KRISTIN
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:KRISTIN
Other - Last Name:NIEMCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4707 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3508
Mailing Address - Country:US
Mailing Address - Phone:770-965-1301
Mailing Address - Fax:
Practice Address - Street 1:224 SHALLOWFORD RD NW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-4171
Practice Address - Country:US
Practice Address - Phone:770-536-1170
Practice Address - Fax:770-536-4653
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist