Provider Demographics
NPI:1881149268
Name:JSA DENTAL ASSOCIATES CONYERS PC
Entity type:Organization
Organization Name:JSA DENTAL ASSOCIATES CONYERS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-483-0029
Mailing Address - Street 1:1151 NOR TEC DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:770-483-0029
Mailing Address - Fax:770-483-0043
Practice Address - Street 1:1151 NOR TEC DR
Practice Address - Street 2:SUITE B
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-483-0029
Practice Address - Fax:770-483-0043
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JSA DENTAL ASSOCIATES MCDONOUGH PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty