Provider Demographics
NPI:1952816373
Name:JENNINGS W BRISTOL DDS PC
Entity Type:Organization
Organization Name:JENNINGS W BRISTOL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BRISTOL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-435-9046
Mailing Address - Street 1:573 CONCORD RD SE STE C
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:573 CONCORD RD SE STE C
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2611
Practice Address - Country:US
Practice Address - Phone:770-435-9046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty