Provider Demographics
NPI:1821207077
Name:DE JESUS, MARIDITH G (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIDITH
Middle Name:G
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 COALTER WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3321
Mailing Address - Country:US
Mailing Address - Phone:973-647-5897
Mailing Address - Fax:
Practice Address - Street 1:3525 BUSBEE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5677
Practice Address - Country:US
Practice Address - Phone:678-836-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN222741223G0001X
GADN1230341223G0001X
FLDN22741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice