Provider Demographics
NPI:1013956606
Name:WELDON, JERRY KENNETH JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:KENNETH
Last Name:WELDON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-5536
Mailing Address - Country:US
Mailing Address - Phone:706-754-1015
Mailing Address - Fax:706-754-3359
Practice Address - Street 1:172 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-5536
Practice Address - Country:US
Practice Address - Phone:706-754-1015
Practice Address - Fax:706-754-3359
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0113861223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics